Affective Disorders Flashcards
(63 cards)
1
Q
affective (mood) disorders
A
-complex behavioral syndromes which are multifaceted and last a minimum period of time and which cause social or occupational dysfunction or significant distress and are not induced by drugs or by a general medical condition
2
Q
timing vs. severity of disease
A
- the earlier the onset, the more severe the disorder
- onset after 40 may suggest medical condition
3
Q
diathesis-stress hypothesis
A
- people have a genetic, biologic and experiential predisposition and vulnerability for illnesses (diatheses) but possessing vulnerability for an illness is insufficient to trigger the development of the illness
- vulnerabilities must interact with life stresses to prompt the onset of the illness
- the greater the person’s inherent propensity for developing an illness, the less stress is necessary for the illness to manifest
4
Q
euphoric, euthymic, dysthymic
A
euphoric = up or high euthymic = in the middle dysthymic = down or sad
5
Q
Major depressive episode
A
- 5 or more symptoms present during same 2-week period; at least one is either 1. depressed mood or 2. loss of interest or pleasure
- weight loss when not dieting
- insomnia, hypersomnia
- fatigue
- feeling worthless or guilt
- diurnal variation in mood; more depressed early in the day
- in children irritability counts, not just depressed mood
- early morning awakening (worst mood of the day)
- recurrent thoughts of death
6
Q
manic episode
A
- can be a career ending event
- mania is much harder for people to understand or to tolerate than depressed mood episode
- most will have more than one manic episode
- persistently elevated, expansive, or irritable mood lasting at least 1 week
- 3 or more of the following symptoms are present to a significant degree: inflated self-esteem, decreased sleep, more talkative than usual, pressure of talking, flight of ideas, distractibility, increase in goal directed activity, excessive involvement in activities that have high potential for painful consequences
7
Q
hypomanic episode
A
- note that it is hypomanic (less than manic) there is no “hypermanic” state
- need not be as severe or last as long (4 days rather than 7)
- hypomania: euphoric, but not as high as if they were manic. Duration of disturbance isn’t as long and the individual doesn’t need to be hospitalized. Less severe
8
Q
major depressive disorder
A
- must last at least two weeks
- can happen only once but is often recurrent (specifier single or recurrent)
- can be mild, moderate, or severe and with or without psychotic features
- psychotic features can be mood congruent or incongruent (there may be hallucinations as well as delusions)
- look for medical conditions that could affect the condition (anemia, hypothyroid)
9
Q
Bipolar
A
- Bipolar I and Bipolar II
- type of major affective disorder
- major genetic influence
- course of illness affected by life events
- Bipolar I = pt has to have had at least one manic episode (cant be induced by drugs or resulted form a medical condition unless its persistent
- Bipolar II = the occurrence of one or more major depressive episodes and at least one hypomanic episode
- if pt had a hypomanic episode but no manic episodes, they have bipolar II
- if pt had hypomanic and manic episodes, they have Bipolar I
10
Q
Persistent depressive (dysthymic) disorder
A
- presence, while depressed, of two or more of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness
- milder disorder, occurs over protracted time period
- mild, low mood, may not recognize that they are depressed, just think life sucks
- cant have had a major depressive episode for the 2 years it takes to meet the criteria for PDD
11
Q
Cyclothymic disorder
A
- milder, rapid cycling bipolar disorder lasting for at least 2 years (one year in children and adolescents)
- pt usually switch rapidly over a few days or a week from being mildly depressed to being hypomanic (but never meeting hypomanic criteria) and then back again
- during those two years, has not been without sxs for more than 2 months at a time
- sxs cannot be better attributed to a different illness or induced by drugs or other factors
12
Q
unspecified depressive disorder with anxious distress
A
- presence of at least two of the following symptoms during the majority of days and a major depressive episode or persistent depressive disorder:
1. feeling keyed up or tense
2. feeling unusually restless
3. difficulty concentrating because of worry
4. fear that something awful may happen
5. feeling that the individual might lose control of himself or herself
13
Q
unspecified depressive disorder with melancholic features
A
one of the following is present during most severe period of current episode:
- lack of pleasure in all, or almost all, activities
- lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)
three or more of the following:
- depressed mood characterized by profound despondency, despair, or empty mood
- depression that is regularly worse in the morning
- early-morning awakening (i.e., at least 2 hrs before usual awakening)
- marked psychomotor agitation or retardation
- significant anorexia or weight loss
- excessive or inappropriate guilt
14
Q
unspecified depressive disorders with atypical features
A
- features predominate during the majority of days of the current or most recent major depressive episode or persistent depressive disorer
- mood brightens in response to positive events
- two or more of the following:
1. significant weight gain or increase in appetite
2. hypersomnia
3. leaden paralysis (hard to move)
4. longstanding pattern of sensitivity to interpersonal rejection
15
Q
unspecified depressive disorders with psychotic features
A
- specifier applies to recurrent major depressive disorder
- mood congruent psychotic features (content of delusions and hallucinations is consistent with typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment)
- mood-incongruent psychotic features (content of delusions or hallucinations does not involve typical depressive themes, or content is a mixture of mood-incongruent and mood-congruent themes)
- catatonia excessive motor activity - catatonic excitement or poverty of movement/posturing
16
Q
unspecified depressive disorders with catatonia
A
-applies to an episode of depression if catatonic features are present during most of the episode
17
Q
unspecified depressive disorders with peripartum onset
A
-onset of mood symptoms occurs during pregnancy or in the 4 weeks following pregnancy
18
Q
unspecified depressive disorders with seasonal pattern
A
-regular temporal relationship between onset of an episode and a particular time of year
19
Q
major depressive disorder prevalence
A
3% in men and 5-9% in women
- differential expression of dysphoria explanation: women get depressed, men develop alcoholism
- rates higher in women during childbearing years (estrogen related)
20
Q
MDD twins rates
A
- monozygotic = 40%
- dizygotic = 11%
21
Q
risk of MDD for people with relatives with Mdd
A
2-3x higher
22
Q
indicators of more severe MDD disease
A
- earlier onset
- never being married
- more impaired social and occupation function
- poorer quality of life
- greater medical and psychiatric comorbidity
- more negative view of life and the self
- more lifetime depressive episodes and suicide attempts
23
Q
Ages when people are more at risk
A
- caucasians over 65
- recently rates of suicide in middle age are increasing
- average age = 40
24
Q
symptoms of MDD
A
- severe cases may have psychotic features
- may occur gradually or over a short time
- hibernation
- decreased social behavior
- decreased exploratory behavior
- increased need for sleep
- increase or decrease in eating
25
duration of MDD sxs without treatment
many people get better in 6-12 months (25-75%)
26
response, remission, recovery
```
response = <50% improvement
remission = >50% improvement
recovery = >50% improvement for 6 months
```
27
relapse vs recurrence
```
relapse = after remission
recurrence = after recovery
```
28
how does treatment of MDD work
- treatment effects are not as simple as just augmenting the neurotransmitter availability (serotonin or monamines generally)
- important theory: SSRIs downregulate the 1a somatodendritic autoreceptor to increase the cells output of 5HT
29
early onset side effects of SSRIs
- mental agitation and anxiety
- motor restlessness
- parkinsonian or dystonia
- rapid muscle movement myoclonus at night
- inhibition of ejaculation and orgasm
- decreased libido
- nausea
- GI sxs
30
percent of MDD pts that will respond to AD
60% but not necessarily the first one tried
31
Medications for MDD
- first try SSRI
| - if you get a response, but not adequate, add another med to boost effect (non SSRI AD or a mood stabilizer)
32
serotonin syndrome
- nausea, confusion, hyperthermia, autonomic instability, tremor, myoclonus, rigidity, seizures, coma, and death
- can occur when SSRIs ARE COMBINED WITH MAOIs
33
SSRI discontinuation syndrome
-dizziness, lethargy, nausea, irritability, and headaches
34
use of SSRI during pregnancy
- SSRI tx during first trimester has been implicated in increased risks of birth defects, specifically cardiac abnormalities
- use in third trimester has been linked to various neonatal complications including withdrawal and toxicity, prematurity, low birth weight and persistent pulmonary hypertension
35
tx for first onset and of MDD and recurrent MDD episodes
- tx for 6-12 months for first onset
- tx for recurrent episodes = AD dose (maintenance)
- CBT is effective but more costly
36
combining CBT with meds in MDD
shows no increased benefit together except the CBT is likely to prevent relapse
37
role of CBT therapist in MDD
- have pt self monitor for mood
- have patient increase pleasant activities
- address client self-talk, schemas and cognitive distortions
38
seasonal disorders tx
expose patient to longer periods of light, early in the morning and the last thing at night
39
ECT
- electroconvulsive therapy
- only used for severe cases
- only used when there is failed multiple trials of meds and combined treatments
- ONLY USED FOR MDD
40
recommendation in evaluation of bipolar
-same recommendation as for those with MDD
41
average age of tx for bipolar
20-25 yo
- bipolar is increasingly diagnosed in youth
- if onset is after 60yo, the person probably had a stroke
42
concordance rate of bipolar for twins
```
monozygotic = 65-85%
dizygotic = 15%
```
43
tx for people with bipolar in a depressive episode
- SHOULD NOT be treated with AD without presence of a mood stabilizer
- AD without mood stabilizer can precipitate manic episode
44
compounds associated with secondary mania
-corticosteroids, stimulants, metabolic disturbances, infections, and epilepsy
45
hypothesis for how bipolar works
-not enough norepinephrine leads to depression and too much catecholamines (including norepinephrine) can cause mania
46
tx of acute mania
lithium - AP with mood stabilizing properties
47
prophelaxis in bipolar
-mood stabilizers (lithium and depakote) and often an antiseizure medication (lamictal)
48
lithium and lamictal actions
- lithium deals with the high end (mania)
| - lamictal deals with low end (depression)
49
Lithium
- AP with mood stabilizing properties
- pregnancy category D by FDA
- more effective than depakote in preventing suicide
- may affect 2nd messenger system
- treats acute episodes of mania and hypomania
- can prevent recurrent manic episodes and depressive episodes in bipolar
- NOT USED to prevent depressive episodes in unipolar depression (use AD)
50
pharmacology of antidepressants
- all effective ADs have immediate interaction with neurotransmitter or enzyme that affects neurotransmitter
- interact with monoamines (principle NTs are dopamine, serotonin, norepinephrine, and epinephrine)
- most block reuptake of 1 or more monoamines
- some have direct actions on 1 or more monoamines
- desensitization not an immediate process - explains delayed action of most ADs. Takes 2-6 weeks or so to get therapeutic effect
51
Monoamine oxidase inhibitors
3rd line of treatment
- oldest and least used
- irreversible enzyme inhibitors
52
tricyclics
2nd line of treatment
- chemical structure contains 3 rings
- block reuptake pumps of serotonin, norepinephrine, and dopamine by causing transporter to no longer bind to monoamine
Blockade of:
1. muscarinic cholinergic receptors (cholinergic side effects, dry mouth, blurred vision, urinary retention, constipation)
2. histamine type 1 (wt gain)
3. alpha 1 adrenergic receptors (orthostatic hypertension and dizziness)
-these all account for side effect profile
small amounts of overdose IS LETHAL
-also used for chonic pain
53
SSRIs
1st line of treatment
- selective and potent inhibition of serotonin reuptake
- MINIMAL RISK OF SUICIDE
- MOA: down regulation and desensitization of receptors; neuron is less sensitive to its own serotonin production so it doesnt turn itself off
54
side effects of SSRIs
- generally acute; anxiety or agitation due to acute stimulation of 2a and 2c receptors
- 2a receptor stimulation can also produce akathesia, psychomotor retardation, mild parkinsonism, and dystonic movements
- myoclonus at night, nocturnal awakening
- inhibition of spinal reflexes of orgasm and ejaculation
55
antipsychotics
- may use for bipolar manic phase
| - debate about using them for psychotic depression (most start with AD and as depression resolves, psychosis resolves)
56
side effects of lithium
nausea, vomiting, diarrhea, wt gain, hair loss, tremors, sedation, cognitive SE and incoordination
-potential long-term thyroid and kidney problems
57
Anticonvulsants
- based on theory that mani may kindle (may produce further episodes of mania - bipolar diathesis model)
- MOA is unclear
- Depakote is most common
- appear to act on Na-K-Ca ion channels and interfere with Na movement which thereby boosts CABA's inhibitory action. Reduces glutamate activity
58
depakote
anticonvulsant
- used as a mood stabilizer and considered 1st line for bipolar
- SEs = hair loss, wt gain, sedation, tremor, motor skills deficits, can cause neural tube defects in developing fetus
59
Lomotrigine
Lamectal
- inhibits Na channels and release of glutamate
- anticonvulsant
60
Gabapentin
Neurontin
- interacts at GABA receptor and increases GABA levels
- anticonvulsant
61
Topiramate
Topamax
| -anticonvulsant
62
benzodiazepines
may be used as an adjunctive in treatment of agitation in psychosis and mania
63
lithium and lamictal
often used in combo
- lithium provides stronger coverage at high end
- lamictal provides better coverage at the low end
- lamotragine appears to be particularly effective in long term prophylaxis
