Psychiatry SC073: I Am Depressed: Mood Disorders Flashcards
Depression always pathological?
Mood fluctuations in responses to disappointment, frustration, losses in everyday life
- Usually short-lived
- Natural despondency can have important **survival function, resulting in **reorientation + ***maturation
Major depressive disorder:
1. **Severe symptoms
2. **Impair adaptations, often disabling
- when enduring, depression can result in impaired function at work, school, in family
Epidemiology:
- >300 million worldwide
- Increase by >18% from 2005-15
- **F:M ~ 2:1
- Average lifetime and 12 month prevalence estimates of MDD: **14.6% and 5.5% in the ten high income and 11.1% and 5.9% in the eight low to middle income countries
- One of leading causes of total DALYs for 1990, 2006, 2016
- One of major causes of **suicide —> 20x↑ in suicide risk
- Increases **non-suicidal mortality (RR 1.2-4) —> Possible mediators:
1. Behavioural risk factors (e.g. poor adherence to treatment, inactivity, ↑ alcohol consumption)
2. Biological risk factors (e.g. altered thrombogenesis)
3. ↑ Subclinical disease / Prevalent disease (e.g. CVS disease)
Clinical presentations of Depression
***Can vary!!!
First obvious sign in Younger people may be:
1. **Loss of interest in friends
2. **Decline in school performance
3. **Self-injury / **Bulimia / Drug use in a previously stable adolescent
Some older people, symptoms may mimic ***dementia
1. Deterioration of cognitive functioning + self-care
Some case may not have symptoms / masked until found dead by suicide
ICD-10 criteria of Depression
ICD-10:
Cardinal symptoms:
1. Depressed mood
2. Loss of interest (Anhedonia)
3. Loss of energy (Anergia)
Additional symptoms:
4. Reduced concentration
5. Reduced self esteem (present)
6. Guilty feelings (past)
7. Hopelessness and pessimism (future)
8. Self harm / suicidal ideas
9. Sleep disturbance
10. Decreased appetite
11. Loss of libido
12. Psychomotor changes
***DSM-5 criteria of Depression
Major depressive disorders:
1. **>=2 weeks
2. Symptoms cause clinically **significant distress / impairment in social, occupational or other important areas of functioning
3. Episode **not attributable to physiological effects of a substance / another medical condition
4. Not better explained by **schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, other specified and unspecified schizophrenia spectrum and other psychotic disorders
5. Absence of previous **manic / hypomanic episode
6. **Clear-cut changes in affect, cognition, neurovegetative functions
-
**>=5 following symptoms, >=1 is either (1) / (2)
—> (1) **Depressed mood (most of the day, nearly every day) (indicated by subjective report / observation by others / irritable mood in children or adolescents)
—> (2) **Markedly diminished interest / pleasure in all / almost all, activities (most of the day, nearly every day) (either subjective account / observation)
—> (3) **Significant weight loss / weight gain (>5% BW in a month) / appetite increase / decrease (nearly every day) (failure to make expected weight gain in children)
—> (4) **Insomnia / Hypersomnia (nearly every day)
—> (5) **Psychomotor retardation / agitation (nearly every day) (observable by others, not merely subjective feelings of restlessness or being slowed down)
—> (6) **Fatigue / Loss of energy (nearly every day) (沒精打彩)
—> (7) **Feelings of worthlessness / excessive / inappropriate guilt (which may be delusional) (nearly every day) (not merely self-reproach / guilt about being sick) (記: Uselessness, Hopelessness, Helplessness, Guilt)
—> (8) **Diminished ability to think / concentrate / indecisiveness (nearly every day) (either subjective account / observation)
—> (9) **Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan / a suicide attempt or a specific plan for committing suicide
Specifiers for major depressive disorder:
1. Course: Single / Recurrent episode
2. Severity: Mild / Moderate / Severe, with **psychotic features, in partial remission, in full remission, unspecified
3. Other specifiers without codes:
- Anxious distress
- Mixed features
- Melancholic features
- Atypical features
- **Mood-congruent psychotic features (與情緒吻合的症狀)
- ***Mood-incongruent psychotic features
- Catatonia
- Peripartum onset
- Seasonal pattern (recurrent episode only)
With melancholic features (憂鬱型抑鬱)
“Distinct quality” of mood
1 of following present during the most severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)
> =3 of following:
3. A distinct quality of depressed mood characterised by profound despondency, despair, and/or moroseness or by so-called empty mood
4. Depression that is regularly worse in the **morning (normal human should feel good in morning since refreshed)
5. **Early-morning awakening (i.e. >=2 hours before usual awakening)
6. Marked psychomotor agitation / retardation
7. Significant anorexia / weight loss
8. Excessive / inappropriate guilt
With anxious distress
- High levels of anxiety have been associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment non-response
- > =2 ***Anxiety symptoms
- Feeling keyed up / tense
- Feeling unusually restless
- Difficulty concentrating because of worry
- Fear that something awful may happen
- Feeling that the individual might lose control of himself or herself
With mixed features
- A significant risk factor for the development of ***Bipolar I / Bipolar II disorder
- Coexistence of >=3 manic symptoms (insufficient for a manic episode)
- Elevated, expansive mood
- Inflated self esteem / grandiosity
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Increase in energy or goal directed activity (either socially, at work or school, or sexually)
- Increased or excessive involvement in activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, foolish business investments)
- Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia)
With atypical features
Does not connote an uncommon / unusual clinical presentation as the term implies
- Mood reactivity (i.e. mood brightens in response to actual or potential positive events)
- > =2 of following symptoms:
- Significant weight gain / Increase in appetite
- Hypersomnia
- Leaden paralysis (i.e. heavy, leaden feelings in arms or legs)
- A long standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social / occupational impairment
With psychotic features
- Delusions / Hallucinations are present
- Mood-congruent psychotic features
- Personal inadequacy, **guilt, disease, death, **nihilism (Cotard’s syndrome (delusion of non-existence 幻想自己無左一d部位) / deserved punishment
- Delusion of **persecution
- Delusion of **poverty
- ***Hypochondriacal delusion - Mood-incongruent psychotic features
- Does not involve typical depressive themes
- Or a mixture of mood-incongruent and mood-congruent themes
With catatonia
Catatonic features are present during most of the episode
With peripartum onset (產前/後抑鬱)
Peripartum:
- 50% of “postpartum” major depressive episodes actually begin prior to delivery
- Onset of symptoms occurs **during pregnancy / within **4 weeks following delivery
- With or without psychotic features
- Infanticide is most often associated with command hallucinations to kill the infant / delusions that the infant is possessed
- Postpartum mood (major depressive or manic) episodes with psychotic features occur in from 1 in 500 to 1 in 1,000 deliveries
With seasonal patterns
- Regular ***temporal relationship between onset of major depressive episodes and a particular time of year (e.g. fall / winter)
- ***Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of year (e.g. depression disappears in the spring)
- In the last ***2 years, 2 major depressive episodes have occurred that demonstrate temporal seasonal relationships + no non-seasonal major depressive episodes have occurred during that same period
- Seasonal major depressive episodes substantially outnumber non-seasonal major depressive episodes that may have occurred over the individual’s lifetime
- Often characterised by prominent energy, hypersomnia, overeating, weight gain + craving for carbohydrates
Key changes from DSM-4
-
**Removal of “Bereavement exclusion”
- Depressive symptoms may be understandable / considered appropriate to significant loss (e.g. bereavement, financial ruin, losses from a natural
disaster, a serious medical illness or disability)
- Exercise of clinical judgment based on individual’s history + cultural norms
- Now considered a **precipitating factor - Dysthymia now changed to ***Persistent depressive disorder (include both chronic major depressive disorder + previous dysthymic disorder)
- Introduction of 2 new disorders
- **Disruptive mood dysregulation disorder: persistent irritability + frequent episodes of extreme, out-of-control behaviour in children up to age 18
- **Premenstrual dysphoric disorder: mood symptoms occur during the final week before onset of menses + improve within a few days of menses
Causes of Depression
- Pathophysiology largely unknown
- Several mechanisms have been proposed
- Depressive disorder is caused a combination of biological + social + psychological factors, which disturb the brain’s capacity for stress management
- Biological hypothesis
- Classical “serotonin hypothesis”
- Genetic factors (3x risk among 1st degree relatives)
- Structural brain changes: volume reduction + decreased quantity of glial cells in subgenual cortex, reduced hippocampal size
- Hormonal changes: dysregulation of HPA axis, ↓ estradiol (in women) / testosterone (in men), ↓ triiodothyronine + TSH, ↓ BDNF level - Psychosocial hypothesis
- Early environment: parental separation, physical / sexual abuse, non-caring / overprotective parenting styles
- Lack of supportive networks, poorly functioning relationships, poor social integration
- Stress + trauma: long term difficulties, recent life events (in particular events that lead to feelings of entrapment and humiliation)
- Personality: sociotropy (a strong need for approval), neuroticism (情緒不穩定性)
- Cognitive theory: **Cognitive distortions, e.g.
**SOAP
—> **Selective abstraction (斷章取義): focusing on a detail and ignoring more important features of a situation
—> **Overgeneralisation (以偏概全): drawing a general conclusion on the basis of a single incident
—> **Arbitrary inference (妄下判斷): drawing a conclusion when there is no evidence for it and even some evidence against it
—> **Personalisation (過度自責): relating external events to oneself in an unwarranted way
—> **Magnification: blowing things out of proportion (web)
—> **Minimisation: downplaying importance of positive thought, emotion, event (SpC Psychi PP)
- Psychoanalytical theory: loss of an “object”, insecure attachments
Classical “serotonin hypothesis”
- Diminished activity of serotonin pathways
- Antihypertensive drug reserpine (deplete monoamine) produced a depressive state
- Diminished monoaminergic activity was detected in brains of decedents of suicide + bodily fluids of people with depression
- Evidence suggests that cause of depression is far more complicated than reduced level of serotonin
- Monoamines: Serotonin + Norepinephrine + Dopamine are relevant to mood regulation, and play an essential role in regulation of other bodily function
Serotonin:
- Affects body temperature
- Regulates sleep and wakefulness
- Mood and impulse control
- Low level of serotonin metabolites in brains of suicide decedents + spinal fluids of depressed patients
- Serotonin functioning also reduces in depressed patients
Norepinephrine:
- Regulates mood + anxiety levels.
- Mood symptoms emerged among patients who took propranolol
Dopamine:
- Regulates motor + mental activity, attention and motivation
- Dopaminergic neurons in ***mesolimbic reward pathway play an important role in motivation, reinforcement + pleasure response
- Diminished in brains of suicidal decedents with depression
Other neurotransmitter:
Abnormal Glutamate, GABA, Substance P have been detected in patients with depression
