Organic affective disorders Flashcards
What is the Triadic Diagnostic System of Mental Disorders?
Classical approach to psychiatric disorders based on Kraepelin’s Layer Rule
What is Kraepelin’s Layer Rule?
- Organic layer
- Endogenous layer - endogenous psychiatric disorder (“psychoses”)
- Exogenous layer - condition related to psychosocial experiences (“neuroses”)
Only when ruling out organic (1) and endogenous (2) layers can you consider the exogenous layer (3)
What is characteristic of Kraepelin’s Layer Rule?
> It is entailed in hierarchical superiority of mood disorders over adjustment disorder
> Not made explicit in ICD-10 or DSM-5
> It is implicit, as the cause of most disorders
What are two key issues with the Triadic Diagnostic System of Mental Disorders?
- Problems with definition of organic disorders
2. Problems with definition of endogenous disorders
What is the problem with the definition of organic disorders in the Triadic Diagnostic System of Mental Disorders?
No clear definition of the threshold for causal relationship between biological disease and psychopathology
- Organic affective disorders: obvious primary biological abnormalities
- Bipolar disorder/MDD: subtle primary biological abnormalities
- Adjustment disorder: no primary biological abnormalities
What is the problem with the definition of endogenous disorders in the Triadic Diagnostic System of Mental Disorders?
No clear definition of the strength of reaction to psychosocial factors and how pronounced biological abnormalities are to be considered endogenous or exogenous
What are the different organic mood (affective) disorders present in the ICD-10?
- Organic manic disorder
- Organic bipolar disorder
- Organic depressive disorder
- Organic mixed affective disorder
What is the aetiology of Parkinson’s disease?
Degeneration of dopaminergic neurons in substantial nigra
- which is located in brain stem
- sends projections primarily to motor system
- complex interactions of dopaminergic and glutamtergic systems in prefronto-striatal loops
What is the proportion of people with Parkinson’s disease attending neurology clinics that suffer from depressive symptoms?
50-70%
How are depression and anxiety associated to Parkinson’s disease?
> Depression or anxiety may precede neurological symptoms of Parkinson’s disease
> People with depression have 3times higher risk of subsequent Parkinson’s
What do we learn form the case report of a 54-year old women that shows signs of depression as a first manifestation of a large intracerebral lymphoma?
> Symptoms: fatigue, loss of interests, persistent low mood, poor appetite, concentration problems
> Daughters noticed their mother’s reckless driving
- > Doctors ordered MRI scan with contrast
- > found lymphoma in right frontal lobe
=> watch out for symptoms that don’t match with depression or bipolar disorder
How are strokes associated to depression?
> More than 50% of stroke patients suffer from depressive symptoms
> Patients with non-organic old age depression show subtle white matter structural damage in areas often affected by small vessel cerebrovascular disease
- i.e. fronts
> Stroke might disrupt network -> increasing vulnerability to depression
How are brain injuries associated to depression?
High proportion of people even with mild closed head injury suffer from major depression
- they show white matter disruption in areas also seen in non-organic major depression
Can an MRI show white matter disruptions?
No
- you need to do a diffusion tensor scan to see them
What are the lead symptoms of dementia syndromes?
Slow progression (over more than 6 months) in:
- impairment of recent memory
- behavioural changes
- impairment of language or speech
- fluctuating confusional states or impairments of attention
- visuo-spatial impairments
What are the potential diagnoses when the lead symptoms of dementia syndromes are rapidly progressive (3-6 months) or subacute (weeks)?
Creutzfeldt-Jakob, autoimmune or inflammatory encephalopathies
-> neurology referral
In which case is epilepsy the cause of an organic-mood disorder?
> Pre-ictal
- dysphoric or depressed mood disappears on remission of seizure
> Inter-ictal (2/3 patients)
- dysthymia, major depressive or dysphoric syndrome, interictal dysphoric disorder:
- > fluctuating symptoms, irritability, pain, anxiety, depressed and elevated mood
What is a pre-ictal epilepsy?
Prodrome of complex-partial seizure (i.e. before full seizure)
What can be the neurological causes of organic affective disorders?
- Parkinson’s disease
- Brain tumour (e.g. lymphoma)
- Cerebrovascular disease (e.g. stroke)
- Brain injuries
- Dementia (e.g. fronto-temporal)
- Epilepsy
What are the hormonal and vitamine-relate organic affective disorders?
- Cushing’s syndrome (chronic hypercortisolism)
- Thyroid dysfunction (severe hyper/hypothyroidism) in adults
- Endocrine disorders
- Vitamine deficiency (e.g. folic acid, vitamin B12)
What are the signs and symptoms of Cushing syndrome (chronic hypercortisolism)?
- Hirsutism (abnormal hair growth)
- Round face
- Hump
- Easy bruising
- Stretch marks
- Abnormal weight gain
What is exogenous hypercortisolism?
Due to cortisol
What is endogenous hypercortisolism?
Most often caused by pituitary tumour
-> indirectly passing adrenal production
What are the neuropsychiatric symptoms of Cushing’s syndrome (chronic hypercortisolism)?
> Initial phase
- manic syndrome (minority)
- irritability (86%)
> Chronic phase
- major depression (57%)
- depressed mood (74%)
- anxiety and panic (66%)
What are the types of thyroid dysfunction?
Excess of thyroid hormones in blood
How is severe hyperthyroidism in adults associated to anxiety and depressive disorder?
> Approximately
- 60% have anxiety disorder
- 31-69% have depressive disorder
> You need marked abnormalities in thyroid function to cause symptoms of affective disorders
- mild abnormalities not clearly associated
What are the symptoms of severe thyroid dysfunction (hyper or hypothyroidism)?
- Psychomotor retardation
- Decreased appetite
- Fatigue lethargy
- Severe cognitive impairment
- Mimic melancholic depression
How are endocrine disorders associated to affective disorders?
There is evidence of associations between affective disorders and endocrine disorders
However, it is a complex process
How is vitamin deficiency associated to affective disorders?
Deficiency in folic acid can lead to developing depression
- percentage higher than vitamin B12 deficiency
-> Folic acid AND vitamin B12 need to be checked simultaneously
What are the various substance/medication-induced affective disorders?
- Drug-induced mania (no causal role from case reports)
- Drug-induced depression
- Substance-withdrawal induced depression
Which drugs have been reported to be associated to mania-induction?
- First monoamineoxidase inhibitor (Iproniazide): 15%
- Dopamine D2 agonist (Bromocriptin): 20%
- Levodopa for Parkinson’s: 12%
- Cortisone and adrenocorticotrophic hormone: 1.5-9%
- Phecyclidine (PCP) (originally anaesthetic)
- D-Amphetamine
Which drugs were reported as potential causes of depressive symptoms?
- Corticosteroids
- Contraceptives
- Interferon-α
- Interleukin-2
- Mefloquine
How is substance-withdrawal associated to depression?
Evidence of causal relationship
> Withdrawal from stimulants, opioids, alcohol dependence regularly associated with dysphoric mood, anxiety, anhedonia
> High rate of depressive disorders among stimulant-dependent patients during early abstinence
> 6% depression rates in male alcohol-dependent patients (no co-morbid prior mood disorders) after a month of abstinence
Which elements play a role in the very high co-morbid mood disorders rates in substance-dependent patients?
> Chronic use of substances
> Failed self-treatment of mood disorders with substance use
What is the lifetime rate of major depressive disorder in opioid-dependent patients?
54%
What is the lifetime rate of major depressive disorder in alcohol-dependent patients?
38%
What is the lifetime rate of major depressive disorder in stimulant-dependent patients?
32%
In which cases can we suspect an organic cause of affective disorders?
> Visual hallucinations
> Focal-neurological symptoms (impairments in CNS)
> Cancers
> Diagnosed systemic disorders
> Diagnosed neurological disorders affecting the brain
> Treatment-resistant chronic course
> Unusual presentation of the patient
(e.g. not bothered by symptoms rather than disturbed)
> Failure to carry out simple activities of daily living
When are executive frontal functions involved?
In all tasks that require active processing
- e.g. internal generation of concepts, task switching
When are executive “frontal” functions regularly impaired in neurological patients?
> Patients with left dorsolateral frontal and subcortical lesions
> Severe psychiatric disorders
> Persistent in some patients even on remission of measurable symptoms
Why are executive functions tests and active neuropsychological tasks useless to differentiate organic from non-organic conditions?
Impaired executive functions are common in non-organic psychiatric disorders
-> use passive neuropsychological tasks
Which type of neuropsychological tasks are passive tasks?
- Recognition memory
- Simple visuo-spatial tasks (e.g. copy circle)
- Naming pictures
- Word to picture matching to test comprehension
What is the meaning of observed impairment in passive neuropsychological tasks?
Organic causes need to be investigated
