Psychiatric Disorders in Women over the Life Cycle

Question 1

Two disorders with > 4:1 F:M psychiatric diagnoses

Answer 1

1. anorexia

2. bulimia

Question 2

Five 2:1 F:M psychiatric diagnoses

Answer 2

1. MDD
2. panic disorder
3. agoraphobia, specific phobia
4. Generalized Anxiety Disorder
5. PTSD
   NOT OCD OR SOCIAL PHOBIA

Question 3

Three reasons why is MDD more common is women?

Answer 3

1. Psychosocial factors
2. Reproductive events
3. biological vulnerability

Question 4

What are some psychosocial factors that contribute to the higher prevalence of MDD in women?

Answer 4

gender-based violence: rape, sexual abuse, domestic violence), socioeconomic status, multiple roles, caregiving responsibilities

Question 5

What are reproductive events that contribute to the higher prevalence of MDD in women?

Answer 5

menstrual cycle, infertility, pregnancy, postpartum period (increased risk of psych admission immediately postpartum), menopausal transition/perimenopause, hormone therapies

Question 6

Why are women biologically vulnerable in respect to MDD?

Answer 6

higher incidence of MDD from puberty to menopause, most suicide attempt admissions during early follicular/late luteal/decreased estrogen (in general, estrogen –> increased serotonin and progesterone –> decreased serotonin)

Question 7

One F > M disorder:

Answer 7

bipolar II

Question 8

4 F < M disorders:

Answer 8

substance abuse, antisocial personality disorder (PD), narcissistic PD, obsessive compulsive PD

Question 9

differences in clinical presentation of bipolar disorder in women:

Answer 9

more mixed episodes more depressive episodes, rapid cycling, later age of onset.

Question 10

differences in clinical presentation of schizophrenia in women

Answer 10

later age of onset (25-35), higher premorbid and social functioning, more “benign” course

Question 11

Pre-menstrual Dysphoric Disorder (PMDD): prevalence

Answer 11

3-8% of menstruating women

Question 12

clinical presentation of PMDD:

Answer 12

onset of sx during the luteal phase with resolution by menses onset (no sx during follicular phase), very severe sx, mood > physical sx, >=5sx in most cycles with marked impairment in social/occupational functioning

Question 13

Mood sx of PMDD:

Answer 13

depression, anger/irritability, affective lability, anxiety, sensitivity to rejection, , poor concentration, sense of feeling overwhelmed, social withdrawal

Question 14

physical sx of PMDD:

Answer 14

lethargy/fatigue, sleep disturbance (usually hypersomnia), appetite disturbance (usually increased), abdominal bloating, breast tenderness, muscle aches/joint pain, swelling of extremities,

Question 15

Treatment of PMDD:

Answer 15

1. Lifestyle interventions
2. SSRIs: fluoxetine, paroxetine, sertraline: immediate effect
3. Yaz OCP (if also being used for contraception)

Question 16

lifestyle interventions effective in treating PMDD:

Answer 16

exercise, chasteberry herbal remedy, calcium, vit B6, magnesium, vitamin E

Question 17

How is PMDD different from pre-menstrual syndrome (PMS)?

Answer 17

In PMS, more physical than mood sx. PMS is not in the DSM.

Question 18

What are the risk factors for depression in pregnancy?

Answer 18

History of depression, poor overall health, greater alcohol use, smoking, unemployment, lower education level, not married

Question 19

Is the prevalence of mood disorders in pregnancy less than, the same as, or greater than that in the general population?

Answer 19

The same (10-15%)!
However, there is a very high relapse rate (50-70%) of mood disorders in women who are treated with antidepressants that need to be terminated for pregnancy.
Exception: for bipolar disorder, the relapse rate is the same as the general population.

Question 20

Treatment of depression in pregnancy:

Answer 20

1. Psychotherapy
2. light therapy
3. ECT, TME
4. omega-3-fatty acids
5. psychosocial support
6. LIMITED psychotropic meds (MINIMIZE!)

Question 21

Are SSRIs safe during pregnancy?

Answer 21

We don’t know. Mixed data regarding teratogenesis. However, Risk of untreated depression and anxiety in pregnancy IS A KNOWN RISK.

Question 22

risk of untreated depression and anxiety in pregnancy?

Answer 22

increased suffering, decreased ability to care for herself/baby, increased risk pre-term delivery, preeclampsia and low birth rate (perhaps due to increased cortisol), increased substance/alcohol/cigarette use, increased risk of postpartum depression.

Question 23

Is post-partum “baby blues” normal?

Answer 23

normal if it’s not persistent (< 2weeks) and non-impairing

Question 24

post-partum psychosis: clinical presentation

Answer 24

onset 24hours-3weeks post-partum: rapid mood swings, insomnia, obsessive thoughts, delusions (commonly involving infant), hallucinations, impaired reality testing, shifting mental status/disorientation/confusion/disorganized behavior, high rate of suicide and infanticide if untreated!!

Question 25

is postpartum psychosis a psychiatric emergency?

Answer 25

YES!!!!!!!!!

Question 26

Risk of relapse with medication termination in postpartum bipolar women?

Answer 26

4x higher risk of relapse of bipolar disorder in postpartum women)
(note: risk of relapse during pregnancy is the same as the general population).

Question 27

prevalence of postpartum psychosis:

Answer 27

1-2/1000 women

Question 28

risk factors of postpartum depression (PPD):

Answer 28

prior anxiety or MDE, marital discord, unwanted/unplanned pregnancy, infant medical problems, lack of social support, low socioeconomic status

Question 29

prevalence of PPD:

Answer 29

10-15%

Question 30

treatment of PPD:

Answer 30

anti-depressants: secreted into breast milk but can do timing, dosing, and monitoring to minimize infant toxicity exposure.

Question 31

clinical presentation of PPD:

Answer 31

normal depression sx + increasing OCD sx: distressing and intrusive thoughts (ex. What if I threw my baby out the window?)

Question 32

perimenopause:

Answer 32

1-5yr pre-menopause characterized by irregular menstrual cycles

Question 33

perimenopause risk of first MDE: increased, same, or decreased?

Answer 33

increased risk of 1st MDE during menopausal transition.

Note: this risk disappears post-menopausal unless you previously had a hx of depression

Question 34

NORMAL mood sx of perimenopause:

Answer 34

low energy, poor concentration, sleep problems, weight changes, libido changes. It is similar to MDD but should NOT have depression, irritability, anhedonia, suicidal ideation, worthlessness

Question 35

Tx of perimenopausal symptoms:

Answer 35

estrogen replacement therapy will help for mild sx but NOT for MDD!

Question 36

prevalence in F=M disorders

Answer 36

OCD, social phobia, schizophrenia, Bipolar I