NB11-5 - Depressive, Bipolar, and Related Disorders and DLAs

Question 1

List the depressive disorders and what they all have in common.

Answer 1

• Major Depressive Disorder
• Persistent Depressive Disorder
• Premenstrual Dysphoric Disorder
• Disruptive Mood Dysregulation Disorder

The common feature of all these disorders is that the patient has low mood without abnormally high mood periods.

Question 2

List and describe the major mood states identified when discussing mood disorders.

Answer 2

• Manic - high mood to the point that it interferes with normal functions
• Hypomanic - high mood but still able to function normally
• Euthymic - normal mood
• Dysthymic - low mood but still able to function normally
• Major Depressive Episode - low mood to the point that it interferes with normal functions

Question 3

What are the diagnostic criteria for major depressive disorder (MDD)?

Answer 3

The patient must have experienced at least one major depressive episode (MDE) and NOT have a history of mania or hypomania.

Question 4

Describe what constitutes a major depressive episode (MDE)?

Answer 4

At least 2 weeks of 5 or more of the following symptoms, one of which must be number 1 or 2:

1. Depressed Mood
2. Anhedonia - inability to feel pleasure
3. Significant weight change (typically weight loss)
4. Insomnia/hypersomnia
5. Loss of energy
6. Psychomotor changes (talks/thinks more slowly/quickly)
7. Feeling guilty/worthless
8. Decreased concentration
9. Thoughts about death or suicidal ideation

Question 5

MDE symptoms can be further classified. Describe that classification system.

Answer 5

Affective (affecting mood itself) - depressed mood and anhedonia

Neurovegetative (affect functions needed to maintain life) - significant weight change, insomnia/hypersomnia, loss of energy

Cognitive (affect thought processes) - psychomotor changes, feeling guilty/worthless, decreased concentration, thoughts of death or suicidal ideation

Question 6

What is the mnemonic used to help memorize MDE symptoms?

Answer 6

SIG-E-CAPS

(SIG: Energy Capsules)

• Sleep changes
• Interest loss
• Guilt
• Energy problems
• Concentration poor
• Appetite change
• Psychomotor changes
• Suicidal ideation

Question 7

What two major factors contribute to the likelihood of someone developing a MDD?

Answer 7

• Genetic Vulnerability
  
  • ~10% in general population
  • ~20% if 1st degree relative has MDD
  • ~30% if MZ twin has MDD
• The presence of both psychological and physical stressors can drastically (depending upon stressor intensity) increase a person’s likelihood of developing a MDD

Question 8

What common findings are present in the neurobiology of patients with MDD?

Answer 8

• Increased amygdala activity
• Chronically active HPA axis leading to chronically high levels of cortisol and cytokines (inflammatory response)
• Decreased volume of hippocampus (possible due to hypercortisolemia)
• Descreased activity and volume of PFC, leading to increased limbic system activity
• Decreased neurotransmission of monoamines

Question 9

What is believed to cause most of the sickness behavior seen in MDD patients?

Answer 9

The increase in plasma [cytokine] causing general systemic inflammation

Question 10

What are the general treatment plans for MDD?

Answer 10

• A variety of psychotherapies (esp. CBT) may help to address some depressive symtoms, especially with milder MDD
• Antidepressant Drugs (ADs) to increase the amount of monamines, especially serotonin and NE. These drugs often take 4-6 weeks before observable therapeutic effect

Question 11

List the common classes of ADs in the order in which they should be tried. Describe how these drugs work and why they are tried in a specific order. Provide a popular example for the top two classes.

Answer 11

1. Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine (Prozac) slow the reuptake of serotonin from the synaptic cleft. Used first because its side effects are rather benign (GI disturbance)
2. Serotonin Norephinephrine Reuptake Inhibitors (SNRIs) like venlafaxine (Effexor) slow the reuptake of serotonin and NE from the synaptic cleft. Used second because increasing synaptic [NE] can cause cardiac side effects.
3. Tricyclic Antidepressants (TCAs) slow the reuptake of serotonin and NE from the synaptic cleft but with a greater focus on NE. Used third because of the increase in cardiac side effects
4. Monoamine Oxidase Inhibitors (MAOIs) prevent monoamine degredation. Used least frequently because the patients have to be put on a tyramine restricted diet to prevent hypertension (no aged cheese, smoked meats, or beer).

Question 12

Answer 12

E

Question 13

What are the diagnostic criteria for persistent depressive disorder (PDD)?

Answer 13

A chronic depressed mood for at least 2 years where the depressed mood can be in the form of:

• A long-lasting MDE or
• Dysthymia: chronic depressed mood plus 2 of the following symptoms:
  
  • appetite irregularities
  • insomnia/hypersomnia
  • low energy
  • low self-esteem
  • trouble concentrating or making decisions
  • feelings of hopelessness

Question 14

List the PDD specifiers and describe when it is appropriate to use them

Answer 14

PDD with persistent MDE - depression is characterized by a prolonged MDE

PDD with pure dysthymic syndrome - depression is characterized by prolonged dysthymia but no MDEs

PDD with intermittent MDEs - depression is characterized by dysthymic periods and MDEs

Refer to image

Question 15

Answer 15

C

Question 16

What are the treatment plans for PDD?

Answer 16

Less severe forms of PDD are often treated using the same psychotherapeutic and pharmacological methods used to treat MDD

Treatment-resistant and/or severe PDDs may be treated using the same brain stimulation therapies used for depression.

Question 17

What are the diagnostic criteria for premenstrual dysphoric disorder (PMDD)?

Answer 17

The following symptom(s) must present the week before menses onset, improve a few days after menses onset, minimize in the week post-menses and be severe enough as to cause clinically significant distress of functional impairment (not PMS):

• mood lability, irritability, dysphoria, and anxiety symptoms
• anhedonia, problems concentrating, lethargy, appetite changes, sleep changes, physical symptoms (ie - breast tenderness, weight gain)

Question 18

What is the treatment plan for PMDD?

Answer 18

Severall SSRIs are approved for PMDD

Question 19

What are the diagnostic criteria for disruptive mood dysregulation disorder (DMDD)?

Answer 19

Child must be at least 6 years old and the following symptoms must begin before age 10:

• Severe temper outbursts at least 3 times/week
• Sad, irritable or angry mood almost daily
• Reaction is disproportionate to situation
• Symptoms are present in multiple settings

Never diagnosed after age 18

Question 20

Briefly describe the controversy around DMDD

Answer 20

DMDD was just recently added to the DSM and many don’t believe it to be a valid diagnostic entity

• DMDD was added so that a child’s irritability would not be mislabeled as a bipolar disorder

However

• Labeling DMDD kids with a depressive disorder (when not depressed) may be just as inaccurate and lead to inappropriate treatment

Question 21

Answer 21

A

Question 22

List the bipolar and related disorders and say what these disorders have in common.

Answer 22

• Bipolar I
• Bipolar II
• Cyclothymic Disorder

All disorders will show high mood

Question 23

What are the criteria for a manic episode?

Answer 23

Abnormally elevated mood or irritability plus increased energy with at least 3 of the following symptoms:

• Inflated self-esteem/grandiosity
• Decreased need for sleep (not insomnia)
• Pressured speech (fast/energetic speech)
• Flight of ideas (and/or racing thoughts)
• Distractibility
• Increased goal-directed activity or psychomotor agitation (purposeless activity)
• Excessive involvement in risky activities

Common thread is a lack of insight

Question 24

What are the criteria for a hypomanic episode?

Answer 24

Same symptoms of a manic episode but are of a lesser severity and must last at least four days.

While hypomania does not cause impairment in functions (like mania) there will still be a very noticeable change in mood that is unequivocally uncharacteristic of the patient.

Question 25

What mnemonic is used to help remember the manic episode symptoms?

Answer 25

DIG FAST

• Distractibility
• Irresponsibility
• Grandiosity
• Flight of ideas
• increase in goal-directed Activity
• decreased need for Sleep
• Talkativeness

Question 26

What are the diagnostic criteria for bipolar I disorder (BPI)? What are other symptoms to BPI patients frequently experience and what is this disorder called?

Answer 26

The patient must have experienced at least one manic episode lasting at least one week (or be bad enough to require hospitalization)

BPI patients often also experience MDEs. If this is the case, the disorder is frequently called manic-depression

Question 27

Which populations are most susceptible to developing BPI

Answer 27

Strong genetic correlation

General Population - ~1%

1st degree relative with BPI - ~20%

MZ twin with BPI - ~80%

Question 28

What chemical imbalance usually drives manic episodes and what are the treatment options for BPI disorder?

Answer 28

Manic episodes are usually driven by an increase in monoaminergic activity.

BPI disorder is usually treated with “mood stabilizers” like lithium, select anticonvulsants, and select antipsychotics. If the mood stabilizers cause or worsen MDEs to an unacceptable level, antidepressants may also be used but is not FDA-approved for BPI due to risk of inducing mania.

Question 29

What are the diagnostic criteria for bipolar II disorder (BPII)?

Answer 29

Patient must experience at least 1 MDE and at least 1 hypomanic episode.

Question 30

What phase of a BPII disorder is most dangerous to the patient and how is it treated?

Answer 30

The MDEs in BPII are more dangerous because they tend to last longer than the MDEs in BPI. More BPII patients tend to commit suicide.

Treatment for BPII is the same as for BPI but with an additional focus on use of the bipolar depressive drugs.

Question 31

What are the diagnostic criteria for cyclothymic disorder? How is this disorder treated?

Answer 31

The patient must have experienced, for at least 2 years, periods of hypomanic symptoms that fluctuate with periods of depressive symptoms. Patient must also have never had an MDE or manic episode (then the diagnosis would be BPI or BPII).

Similar to BPI but the mood shifts are not as extreme

Treatment is similar to BPI (mood stabilizers)

Question 32

Answer 32

A

Question 33

List the mood disorder specifiers and describe when its appropriate to use them.

Answer 33

• -with melancholic features - severe anhedonia, lack of mood reactivity, prodound despondency/guilt, depression worse in morning, significant appetite loss, early morning awakenings
• -with atypical features - weight/sleep increase, mood reactivity, leaden paralysis
• -with psychotic features
  
  • mood-congruent - delusions/hallucinations consistent with the theme of the mood state
  • mood incongruent - delusions/hallucinations not consistent with mood state
• -with catatonia - mutism, immobility, waxy flexibility, stereotypies (repetitive or ritualistic movements, posturing, or utterances)
• -with peripartum onset - during pregnancy or within 4 weeks post-delivery
• -with seasonal pattern - symptoms show consistent temporal relationship with the time of year
• -with rapid cycling - at least 4 mood episodes occur a year

Question 34

Answer 34

Question 35

Answer 35

C

Question 36

List the brain stimulation therapies that exist for mood disorders.

Answer 36

• Electroconvulsive Therapy (ECT)
• Repetitive transcranial magnetic stimulation (rTMS)
• Vagus nerve stimulation (VNS)
• Experimental
  
  • Magnetic seizure therapy (MST)
  • Deep brain stimulation (DBS)

Question 37

Describe what ECT is, how it is done, how it works, its indications & contraindications, side effects, and efficacy.

Answer 37

In general, ECT is the induction of a generalized seizure using electrical stimulation. It is only done for severely depressed and/or manic patients who are treatment resistant or are believed to harm themselves or others before other treatments take effect. It is not done on patients with vascular disease due to BP increases during seizure. The patient is anesthetized and given muscle relaxants to prevent consciousness and injury. Electrode(s) are placed in the frontotemporal region and electrical stimulation is applied to generate a generalized seizure for at least 30 seconds. Three treatments are give a week for 2-4 weeks. Mechanism of action is not clearly understood but ECTs have been rapidly effective at improving mood episodes, only used to improve current mood episode and NOT to prevent future episodes. Initial side effects are headache and memory loss from the times around the ECT treatments. Some are concerned about permanent damage to memory systems but so far there is no evidence of that.

Question 38

Describe what rTMS is, how it is done, its indications & contraindications, side effects, and efficacy.

Answer 38

In general, rTMS involves stimulation of the PFC using magnetic pulses. It is an available option to mood disorder patients who have failed at least 1 medication trial. Each session is 40mins long and is done 5 times a weeks. It usually takes 4-6 weeks before therapeutic benefits start to be seen. Side effects are minimal are typically only transient scalp pain during the sessions.

Question 39

Describe what VNS is, how it is done, how it works, its indications & contraindications, side effects, and efficacy.

Answer 39

In general, VNS is intermittent electrical stimulation of the vagus nerve via an implanted wire and pacemaker. The goal is to alter NE and serotonin tracks in the brain. It used to treat treatment-resistant depression. Contraindications are the same as for other surgeries. Therapeuic effects take several months to see. Side effects are mild and typically involve intermittent couching or hoarseness during stimulation.

Question 40

Describe what MST is and why it is used?

Answer 40

Magnetic stimulation therapy is an experimental brain stimulation therapy that causes focal seizure induction using magnetic stimulation (similar to rTMS). It is similar to ECT but can be more focused on a specific brain area. It can be as effective as ECT with a reduction in the memory loss side effects.

Question 41

Describe what DBS is and why it is used.

Answer 41

Deep brain stimulation is already in use for OCD patients and target sites are being experimented with for treatment of mood disorders.