🤯Psychiatry🤯 - Mood Disorders Flashcards
What are the 3 core symptoms of depression?
Low mood
Low energy
Anhedonia
What are the depression triads?
What features are examined in the Mental State Examination (MSE)?
Appearance and behaviour
Speech
Mood / Affect
Thought (content and form)
Perceptions
Cognition
Insight
What are the most important questions to ask in a history of presenting complaint of depression?
Insidious versus acute onset (e.g. secondary to a life event)
Core/cognitive/biological symptoms
Diurnal variation? (e.g. mood improves throughout the day)
Suicidal ideation/self-harm (thoughts, plans, intent)
Exacerbating and relieving factors (are they taking medication and is it helping? Psychosocial stressors/support?)
Relevant physical health conditions (e.g. hypothyroidism, anaemia, Cushing’s, chronic pain)
What questions would you ask in a past psychiatric history?
Previous episodes? How long did they last?
Did previous episode(s) resolve with or without treatment?
History of any other mental illness? – Important to rule out manic episodes
Previous admissions? (informal versus under the mental health act)
Collateral history (important if patient is being guarded/poor historian)
Medical notes if available
Previous self-harm or suicide attempts
What questions would you want to ask relating to drugs/medications?
What could you consider in a forensic psychiatric history?
Offending as a youth (consider oppositional defiance disorder and conduct disorder), Youth Rehabilitation Orders
Arrests/cautions/incarcerations/forensic mental health act admissions/probation involvement
Include offences that were perpetrated but for which they were not caught
N.B – Co-morbid substance misuse is the biggest risk factor for offending
What are the key points of information you would want to gather in a personal psychiatric history?
Birth & early developmental (e.g. antenatal/perinatal complications, developmental milestones)
Schooling (academic performance, truancy at school and peer relationships/bullying)
Higher/further education
Employment
Psychosexual history
Premorbid personality
What must be considered in a psychiatric risk assessment?
Risk to self
Risk to others
Risk from others
What would be included under “risk to self”?
Current suicidal ideation/plans/intent
Previous attempts (method/how many episodes/how did they feel when they survived)
Self-harm
Self neglect/poor care of physical health
Risk of misadventure (accidental injury due to impulsive and disinhibited acts e.g. in mania)
What would be included under “risk to others”?
Rarer in depression
Thoughts/plans to harm others
Command hallucinations (general risk factor for violence)
Relevant forensic history
What would be included under “risk from others”?
Vulnerability to exploitation
Risk of retaliation from others (esp. in manic states when overfamiliar, irritable, disinhibited)
What are the main differentials to also consider when considering a mood disorder?
Bipolar disorder vs unipolar depression
Bipolar disorder vs borderline personality disorder/EUPD
Depression vs psychotic prodrome
Psychotic depression vs schizoaffective disorder (depressive type)
Mania vs schizoaffective disorder (manic type)
Hypomania vs Attention Deficit Hyperactivity Disorder
In the context of personality disorders, what is the definition of paranoid?
Pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
In the context of personality disorders, what is the definition of schizoid?
Lack of interest and detachment from social relationships, apathy, and restricted emotional expression
In the context of personality disorders, what is the definition of schizotypical?
Extreme discomfort interacting socially, and distorted cognition and perceptions
In the context of personality disorders, what is the definition of antisocial?
Pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour
In the context of personality disorders, what is the definition of borderline?
Pervasive pattern of abrupt mood swings, instability in relationships, self-image, identity, behaviour andaffect, often leading to self-harm and impulsivity
In the context of personality disorders, what is the definition of histrionic?
Pervasive pattern ofattention-seekingbehaviour and excessive emotions
In the context of personality disorders, what is the definition of narcissistic?
Pervasive pattern ofgrandiosity, need for admiration, and a perceived or real lack of empathy
In the context of personality disorders, what is the definition of avoidant?
Pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation
In the context of personality disorders, what is the definition of dependent?
Pervasive psychological need to be cared for by other people
What are the similarities between bipolar affective disorder (BPAD) and borderline personality disorder (BPD)?
Rapid mood changes
Unstable interpersonal relationships
Impulsive sexual behaviour
Suicidality
In the context of personality disorders, what is the definition of obsessive-compulsive personality disorder?
rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct fromobsessive-compulsive disorder)
What are the main differences between BPAD and BPD?
BPAD is episodic, BPD changes over the course of hours/days rather than days/weeks
BPAD typically features grandiosity, BPD features fear of abandonment, feeling of emptiness and poor self-image
BPAD mood states are typically less affected by environment
BPAD is very heritable
Outline BPAD vs schizoaffective disorder
Both can both can present with psychosis and mood symptoms (both depression and mania)
Typically in Schizoaffective disorder there is more prominent disorganisation of thought, paranoid delusional beliefs and auditory hallucinations
What are the similarities between BPAD and ADHD?
Hyperactivity
Impulsivity
Impaired concentration
Impairment of executive function
Abnormal working and short term memory
What are the differences between BPAD and ADHD?
BPAD not necessarily present in childhood
BPAD is episodic
BPAD shows strong family history (heritability+++)
BPAD features recurrent depressive episodes
In BPAD, amphetamines worsen mania
What are the possible organic causes for mood disorder symptoms?
Endocrine
Systemic
Deficiencies
Neurological
Medications
What endocrine issues can cause mood disorder-like presentations?
Hyper/hypothyroidism
Hyper/hypoparathyroidism
Hypoglycaemia
Cushing’s syndrome
Addison’s disease
What systemic issues can cause mood disorder-like symptoms?
Viral infections
SLE
HIV
Cancers
Cytokines manifested in systemic diseases are considered to be a cause of depression
What deficiencies can cause mood disorder-like symptoms?
Vitamin B12
Folic acid
What neurological issues can cause mood disorder-like symptoms?
Multiple sclerosis
Alzheimer’s
Parkinson’s
What medications can cause mood disorder-like symptoms?
Beta-blockers
Steroids
anti-Parkinson’s
Some antibiotics (e.g. ciprofloxacin)
Statins
Oestrogen
Opiates
Acne medications
What is the DSM-5 criteria for a depressive episode?
2 weeks or more of depressed mood
AND
4 out of 8 of:
Sleep alterations (insomnia or hypersomnia)
Appetite alterations (increased or decreased)
Diminished interest or anhedonia
Decreased concentration
Low energy
Guilt
Psychomotor changes (agitation or retardation)
Suicidal thoughts
How is Major Depressive Disorder (MDD) diagnosed?
Current major depressive episode
No manic or hypomanic episodes in the past
Leads to a longitudinal diagnosis of Major Depressive Disorder (MDD)
What are the subtypes in DSM-5 MDD?
Atypical features (which represent mainly increased sleep and appetite, along with heightened mood reactivity)
Melancholic features (defined by no mood reactivity, along with marked psychomotor retardation and anhedonia)
Psychotic features (the presence of delusions/hallucinations)
What are the DSM-5 criteria for a manic episode?
Euphoric or irritable mood
3 or more of the 7 manic criteria:
Decreased need for sleep with increased energy
Distractibility
Grandiosity or inflated self-esteem
Flight of ideas or racing thoughts
Increased talkativeness or pressured speech
Increased goal-directed activities or psychomotor agitation
Impulsive behaviour (such as sexual impulsivity or spending sprees)
What is unipolar vs bipolar depression?
Unipolar depression is just MDD
Bipolar depression occurs in individuals with bipolar disorders - mood swings that include depressive episodes (as well as mania/hypomania)
What are the differences in the ages of onset between unipolar and bipolar depression?
Bipolar has early age of onset (mean 19yrs)
Unipolar has later onset (late 20s) - however can also be commonly diagnosed in children
How do the lengths of depressive episodes compare in unipolar and bipolar disorder?
Shorter depressive episodes in bipolar
(≈3 months vs 6-12months)
What is different about the course between unipolar and bipolar depression?
Bipolar has a recurrent course
More frequent episodes in bipolar - rapid cycling
(Four or more episodes yearly happening in about 25% of bipolar illness cases, but in <1% of unipolar depression cases)
Is there any genetic specificity linked with unipolar or bipolar depression?
Manic episodes were found in families of persons with manic episodes
Not in families of persons with unipolar depression
What are the treatments for unipolar and bipolar depression?
Unipolar - antidepressants
Bipolar - neuroleptics and lithium
What is it important to note about the distinctions between bipolar and unipolar depressions?
The distinctions are not set in stone - real life has many blurred lines
Since introduced in 1980, many of these distinctions have been weakened or even refuted
What is the leading hypothesis for the mechanism of major depression?
The monoamine deficiency hypothesis
Depressive symptoms arise from insufficient levels of monoamine neurotransmitters serotonin (or 5-hydroxytryptamine , 5-HT), norepinephrine, and/or dopamine
What is the indirect evidence for 5-HT hypofunction in depression?
5-HT depletion by the antihypertensive drug reserpine could cause depression
Clinically useful antidepressants all increase synaptic monoamine
Post-mortem evidence of reduced 5-HT levels
Lower levels of 5-HT1A-receptors and 5-HT4-receptors
Monoamine depletion correlates with decreased mood both in at risk and MDD in remission
How can we quantify dopamine and dopamine receptors?
How is release of cerebral 5-HT measured?
5-HT2A agonist PET tracer
Use of [11C]Cimbi-36 , a 5-HT2A agonist PET tracer, in combination with amphetamine as the pharmacological challenge
What is the onset for psilocin/psilocybin?
Oral: ≈4-5hrs
IV: ≈1hrs
What is the onset of ayahuasca/DMT?
Oral: ≈4-5hrs
Smoke/IV: 10-20min
What is the onset for LSD?
Oral: ≈10-12hrs
IV: ≈1hr
The structure of which neurotransmitter do tryptamine psychedelics closely resemble?
Serotonin; 5-HT
How do SSRIs and psychedelics act on the serotonin system?
SSRIs - reuptake inhibition
Psychedelics - act as agonists at the 5-HT2A receptor
Where are the 5-HT2A receptors located?
Abundant in regions involved in perception, cognition and emotion
Cortical areas
What are the pros and cons of psychedelics?
Safe: Non-addictive, low physiological and brain toxicity, good therapeutic index
Risks: Dysphoria/anxiety, nausea, headache, hidden vs false memories
Overall - safety of classic serotonergic psychedelics well-established
What are the effects of classic psychedelics in depression?
(particularly psilocybin +++)
Decrease in depression
Decrease in depression in BPD-II
Increase in wellbeing and decrease in suicidality
