Oct15 A1,2-Mood Disorders Introduction Flashcards
nuance to know in mood disorders
- episodes and disorders are diff things described
- criteria help dx an episode
- then dx a disorder in a certain way
3 groups of symptoms for depression episode dx and done how
- feeling (2)
- physical (4)
- thinking (3)
- must have 5 of 9 for 2 weeks* AND see significant clinical distress or impairment (occupational, social, other) AND exclude substances (drugs and meds) or medical causes
2 ‘‘feeling’’ sx of depression
- depressed mood (sadness or numbness)
- loss of interest (anhedonia)
4 ‘‘physical’’ sx of depression
-sleep changes (insomnia. specifically initial insomnia most frequently and sometimes early awakening insomnia) (rarely, atypical = sleep too much)
-decrease in apetite
(bc of anhedonia) + weight changes (rarely, atypical = eat too much and gain weight)
-loss of energy and fatigue
-motor slowing (possibly with pain), agitation
3 ‘‘thinking’’ sx of depression
- poor concentration, indecisiveness, mental slowing
- worthlessness and guilt (for things done before, which is normal, or things it’s abnormal to be worried about)
- suicidal ideation
types of insomnia
- initial insomnia = beginning of the night (can’t fall asleep) = most common in depression. also bc of stress in life
- middle insomnia (interruptions in the night)
- terminal insomnia (early morning awakening) (also possible in major depression but is more serious)
continuum of suicidal thoughts
- I wish I wasn’t around, I wasn’t born, I didn’t wake up
- It wouldn’t matter if I fell, if I got hit by a car
- plan suicide
concept about depression tx
each category of symptoms (feeling, physical, thinking)
antidepressants in depression
- increase mood and sense of well being
- helps for the physical sx
social support in depression
helps being in new environment being isolated is a risk factor for depression
structured physical activity in depression
for mild to moderate depression
- helpful for tx
- getting things done, going out the house regularly, etc.
sleep hygiene in depression
- sleep 7 to 9 hours in one period over 24 hours
- usually between 11 pm and 7 am
- 5 hours of continuous sleep helps you get 80% of sleep debt so is very important (so pt woke up at 4 or 5 am = less worried than if wake up at midnight)
- no naps
light therapy in depression
light therapy lamps to use if people have seasonal frequency to their illness
- schedule thing
- wake up early to expose themselves to light
- start to use usually in November
cognitive behavioral therapy and interpersonal therapy (IPT) in depression
helpful, especially for the thinking sx (poor conc, mental slowing, indecisiveness , worthlessness and guilt + suicidal ideation)
mania episode groups of sx + dx done how
- feeling (1)
- physical (3)
- thinking (4)
- need 4 out of 8 sx for 1 week* AND see significant clinical distress or impairment (occupational, social, other) AND exclude substances (drugs and meds) or medical causes
feeling sx in mania (1)
elevated euphoric mood + sometimes irritable (when know they’re annoying for others after many episodes)
physical sx in mania (3)
- decreased need for sleep (really energized, do same nbr of activies as usually but in 2-3 hours)
- talkative and pressure speech (faster speech rate)
- psychomotor agitation
thinking sx in mania (4)
-increased goal-directed activity (busy and organized schedule, move a lot, understand others well, very focused, feel like given a mission, do mass communication, very distractible) -flight of ideas, racing thought -distractibility -pleasurable risky behavior
hypomania episode criteria and dx done how
- feeling (1)
- physical (3)
- cognitive and thinking (4)
- need 3 (if expansive elevated mood) or 4 (if irritable mood) out of 8 sx for 4 week* AND change in functioning WITHOUT impairment AND exclude substances (drugs and meds) or medical causes
feeling sx (1) in hypomania episode
elevated, expansive or irritable mood
physical sx (3) in hypomania episode
-decreased need for sleep
-talkative pressured speech
-psychomotor agitation
(same physical sx as mania episode)
enjoy it bc can get a lot done
cognitive, thinking sx (4) in hypomania episode
-increased goal-directed activity
-flight of ideas, racing thoughts
-distractibility
-pleasurable, risky behaviour
(same as thinking sx of mania episode)
problem of misdiagnosing bipolar type 2 (depression + hypomania) patients by saying they have depression
we then give them an antidepressant and they go into full mania (meaning we switched them into bipolar type 1)
- have to remove antidepressant
- keep them on usual med (mood stabilizer) for bipolar disorder
- importance of hx and asking about sx after start the meds*
tx principle in manic and hypomanic episodes
specific tx approaches for each sx group
tx in mania
- mood stabilizer (NO antidepressant) = helps feeling sx
- sedative, quiet physical location and less or no socializing help for physical sx (last one for reputation)
- brief focused interactions, tell them the painful consequences, decrease environment stim, temporarily restrict access to risky activities, promote relaxation = helps for thinking sx
2 categories of mood disorders in the DSM-V
- bipolar and related disorders
- depressive disorders
3 types of bipolar and related disorders
- bipolar 1
- bipolar 2
- cyclothymia
how to dx bipolar type 1
one manic episode + one major depressive episode
- possible to dx it with a single manic episode (but 90% also have a major depressive episode hx, usually burnout after the manic episode, 3 months after being ‘‘high’’)
- be careful in psychotic pts bc dangerous situations, do good hx to check if was caused by mania
- mania + psychosis = diff tx than psychosis alone
burnout after mania vs depression after mania
ask patient what they would do if had more energy
- the manic pt tells you what they would do
- the depressive pt can’t answer
bipolar type 2 dx done how
same thing as bipolar type 1 but is one hypomanic episode + one major depressive episode
-always check if depressive pts have had a hypomania episode bc if give antidepressant to a bipolar type 2 pt, will switch into full mania (bipolar type 1)
dopamine and NE tx vs serotonin tx
- dopamine and NE for energy
- serotonin for well being
cyclothymia dx done how
- minimum of 2 years
- hypomanic sx and depressive sx
- sx present most of the time
- no period of 2 months where symptom free
- no full episodes
- not common. usually women who have fluctuations with mood with menstrual cycle*
types of depressive disorders (depressive disorders = 2nd thing in the mood disorder classif of DSM)
- major depression
- dysthymia (persistent depressive disorder, PDD)
- premenstrual dysphoric disorder (PMDD)
major depression dx + tx
- one major depressive episode
- you give an antidepressant
- meds or not, you won’t have another episode before a year just bc of the natural hx of depression so help pt in the meantime
dysthymia (persistent depressive disorder) dx (basically depression sx most days)
- minimum 2 years
- depressed most days
- 2+ sx present most of the time (poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor conc or difficulty making decisions, feeling of hopelessness)
- no period of 2 months sx free
- no full episodes
- possible to have both a major depressive episode and dysthymia*
what are secondary mood disorders
caused by substances or meds or medical disorder
- anything that promotes dopamine (cocaine, levodopa)
- hypoT mimics depression. hyperT mimics mania
- MS looks like mania in beginning and get depressed overtime
parts of clinical assessment in psychiatry
- ID
- chief complaint
- pmhx
- meds
- psych hx
- fhx
- habits
- hpi
- personal and social hx
how ID helps for mood disorders
- age: depression risk decreses with age
- sex: depression and bipolar II 2x more common in F. no diff M vs F for bipolar I (like schizophrenia)
- marital status: divorced or separated = increased risk of depression
- multiple divorcers = increased risk of bipolar
- employment and productivity are protective
- high income is protective
how chief complaint helps for dx of mood disorder
check the feeling, physical and thinking sx
how psych hx helps for dx of mood disorder
- anxiety disorders (common). (not full blown disorder but episodes or generalized anxiety)
- substance misuse and disorders (bipolar pts enjoy cocaine and things that mimic hypomanic or manic state. alcohol can make pt depressed later)
- suicide attemps
how FHx helps for dx of mood disorder
- genetic predisposition to depression increases risk by 2-4x
- familial non genetic risk (exposure to depressed parent, compromised parenting, neglect)
- bipolar fhx increases risk of 10x (same as schizophrenia which has 1-10% baseline risk)
- fhx of suicide attemps or completed increases risk for pt
how pmhx helps for dx of mood disorder
other illnesses assoc with depression neuro: -PD -epilepsy -diabetes -migraine -stroke cardiovascular: -metabolic syndrome -MI other: -lupus -cancers -Crohn's -chronic illnesses (pain, IBS, fibromyalgia)
how meds in clinical assessment in psychiatry can help for dx of mood disorders
- dopamine (levodopa) assoc with mania
- topiramate, reserpine, amiodarone (via thyroid), digoxin, phenobarbital and maybe interferon + CCB for BP are all assoc with depression
how HPI helps for dx of mood disorders
- stressful life events
- lack of social support
- emotional coping (is one of the 3 types of coping. is assoc with depression) = obsession over a negative event going on now or in the past. distraction, avoidance and sleep is another type of coping. problem solving and brainstorming is the best type of coping
- negative cognitive style (make a negative evet your fault)
- sleep-wake cycle disturbances (assoc with bipolar). travel across time zones = RF to switch from euthymia to hypomania or mania)
how personal hx helps for dx of mood disorders
- childhood SES (parental occup and educ, deprivation, poverty, safety)
- childhood adversity (early trauma) (parental loss, physical abuse, neglect, harsh parenting, psychological. these can be caused by the parent having depression. increase risk of depression and bipolar)
- level of education (higher is protective)
- neuroticism (overthinking) = RF for depression, bipolar and psychosis
- greater problems adapting life difficulties, transitions
- high interpersonal dependence
2 major categories of mood disorders
- depressive
- bipolar (types 1 and 2)
most common mood disorder
depression
imp thing to get correct dx in mood disorders
search for hypomanic and manic episodes
- inappropriate tx of bipolr I or II with antidepressant can worsen the prognosis of the mood disorder
- can use mood disorder questionnaires to help (for lifetime sx of mania)
conceptual model of mood disorders
- non-modifiable risks (age, sex, shared genes, contact with sick relatives, bereavement, childhood adversity) and modifiable risks (acute events, chronic stressors, support, coping, medical illness, meds, anxiety disorders) define vulnerability
- they lead to the mood sx (changes in sadness and euphoria, pleasure and interest, energy, activity, sleep, appetite and weight, psychomotor, concentration, attention, grandiose ideas, suicidal ideas)
