Affective Disorders

Question 1

Describe the ICD-10 criteria for Bipolar disorder

Answer 1

2+ episodes of depression and mania/hypomania

• in the absence of mania/hypomania, diagnosis = recurrent depressive disorder
• in the absence of depressive episodes, diagnosis is either bipolar or hypomania

Question 2

1. What gender is affected more by bipolar?
2. what is the mean age of onset?
3. In which SES group is prevalence highest?

Answer 2

1. both genders affected equally
2. 21
   
   • first episode of mania after 50 is unusual and should lead to investigation of organic cause
3. higher SES groups

Question 3

Which neurotransmitters are implicated in the aetiology of bipolar disorder?

Answer 3

NA, DA and 5-HT

Question 4

Define the following classifications of bipolar disorder:

1. Bipolar Disorder type I

2. Bipolar Disorder type II

Answer 4

1. at least one manic or mixed episode

2. never had a full manic episode; at least 1 hypomanic episode and at least one major depressive episode

Question 5

Describe clinical features of Mania

Answer 5

• elevated mood
• increased energy
• thought disorder - racing thoughts, flight of ideas, pressured speech
• increased self esteem
• reduced attention, distractability
• Tendency to engage in behaviour that has serious consequences
• Marked disruption of work, usual social activities, and family life
• may display psychotic symptoms such as grandiose ideas, persecutory delusions
• Preoccupation with thoughts and schemes may lead to self-neglect, to the point of not eating or drinking, and poor living conditions.
• total or partial loss of insight

must last >1 week

Question 6

Describe clinical features of hypomania

Answer 6

• mildly elevated, expansive or irritable mood
• increased energy and activity
• marked feelings of well-being, physical and mental efficiency
• increased self esteem
• sociability
• talkativeness and over-familiararity
• increased sex drive
• reduced need for sleep
• difficulty in focussing on one task alone

Question 7

How does hypomania differ from mania?

Answer 7

• shorter time
• less severe
• no psychotic features
• less disability

Question 8

1. Name 5 other psychiatric differentials for bipolar disorder
2. name 4 organic differentials for bipolar disorder

Answer 8

1. schizoaffective disorder
   schizophrenia
   cyclothymia
   ADHD
   drug use - alcohol, amphetamines, cocaine, hallucinogens

2. organic brain disease of the frontal lobes
   endocrine disorders - hyperthyroid, cushing’s
   SLE
   sleep deprivation

Question 9

1. How is an acute manic episode managed? (3)

2. What are the 3 main pharmacological options for long term management?

Answer 9

1. sedative (e.g. diazepam)
   neuroleptic (e.g. haloperidol)
   atypical antipsychotic (e.g. olanzapine)

2. lithium
   valproate
   carbamazepine

Question 10

1. How long does lithium treatment need to be taken for?
2. How is lithium excreted?
3. Which organ function needs to be monitored during lithium therapy? (2)

Answer 10

1. at least 3 years
2. unchanged by the kidneys (therefore plasma concentration can be affected by renal function)
3. renal function
   thyroid function (can cause hypothyroidism)

Question 11

Why should antidepressants be used conservatively in the management of bipolar disorder?

Answer 11

they have the potential to induce mania (manic switch) or rapid cycling

Question 12

What is meant by the terms:

1. attempted suicide
2. parasuicide
3. deliberate self harm

Answer 12

1. an act of intentionally trying to kill oneself, with the primary aim of dying, but failing to do so
2. an act that looks like suicide but does not result in death. Can be tantamount to attempted suicide, or a means of help seeking
3. the act of intentionally inuring oneself, irrespective of the actual degree of injury sustained.

Question 13

Out of deliberate self harm and suicide, which is more common in:

1. men?
2. women

Answer 13

1. suicide

2. deliberate self harm

Question 14

1. In which gender is suicide more common in?
2. How is suicide affected by age?
3. Name other sociodemographic risk factors for suicide

Answer 14

1. men
2. rate is highest in males aged 25-44; rate increases with age

3. single/widowed/separated
    unemployment/insecure employment
    lower SES
    poor levels of social support - elderly, prisoners, immigrants, bereaved
    recent life crisis
    victim of physical or sexual abuse

Question 15

Name some clinical risk factors for suicide

Answer 15

• hx of deliberate self harm
• hx of mental disorder - alcohol dependence, schizophrenia, depression
• physical illness (particularly if terminal or disabling)
• fam hx

Question 16

What questions are important to ask when assessing a patient’s suicide risk?

Answer 16

• was there a clear precipitant/cause for the attempt?
• was the act premeditated or impulsive?
• did they leave a suicide note?
• had the patient taken steps not to be discovered?
• did the patient make the attempt in strange surroundings?
• would the patient do it again?

Question 17

What are the absolute indications for a psychiatric referral following a suicide attempt?

Answer 17

• clinical depression
• psychotic illness
• clearly pre-planned suicidal attempt that was not intended to be discovered
• persistent suicidal intent (more detailed plans)
• violent method used

Question 18

What other factors could indicate a referral to psychiatry following a suicide attempt?

Answer 18

• alcohol/drug misuse
• patients <45, especially if male, and young adolescents
• fam hx of suicide
• those with serious physical disease
• those living alone or otherwise unsupported
• major unresolved crisis
• persistent suicide attempts
• patients giving you a cause for concern

Question 19

Name reasons that a person may perform deliberate self harm

Answer 19

• express and relieve bottled up tension/anger/emotion
• feel more in control of a seemingly desperate life situation
• punish oneself for being a “bad person”
• combat feelings of numbness
• distract oneself from other pain

Question 20

Name risk factors for repeated parasuicide

Answer 20

• hx of suicide attempt
• hx of trauma
• poor global functioning
• hx of psychiatric disorder/undergoing psychiatric treatment
• alcohol/drug abuse/dependece
• PERSONALITY DISORDER
• unemployment
• unmarried status
• interpersonal conflict

Question 21

Name risk factors for repeated deliberate non fatal self harm

Answer 21

• hx of self harm
• hx of psychiatric disorder/psychiatric treatment
• personality disorder
• alcohol/drug use/dependence
• living alone

Question 22

How is a person who has performed self harm managed:
1. Acutely?

2. In the long term?

Answer 22

1. sensitive and compassionate approach
   see patient individually
   examine physical injuries
   assessment of emotional/mental state and risk
   address any safeguarding concerns
   refer to A&E if physical state is considered high risk
   consider referral to secondary mental health services
2. harm minimisation techniques
   development of alternative coping strategies
   psychological intervention
   crisis team involvement
   management of other mental/physical health problems
   prevent access to any means of self harm where possible

Question 23

Which personality disorder is associated with repeated acts of deliberate self harm?

Answer 23

Borderline personality disorder

Question 24

1. What is the prevalence of depression in primary care?
2. What is the prevalence of depressive symptoms in the general population?
3. How is the prevalence of depression affected by age?
4. In which gender is the prevalence of depression higher?

Answer 24

1. 10-15%
2. ~30%
3. increases with age
4. females

Question 25

1. Which 3 neurotransmitters are implicated in depression? 2. What is the normal role of these neurotransmitters? 3. How are they affected in depression?

Answer 25

1. DA, NA and 5-HT (monoamines) 2. NA - sleep/wakefulness, eating behaviour and attention DA - motivation 5-HT - mood, sleep/wakefulness, emotional behaviour and sexual function 3. deficiency of monoamines

Question 26

1. Which personality traits are associated with a predisposition to depression? 2. Name other environmental factors which may predispose an individual to depression

Answer 26

1. neuroticism and obsessionality | 2. adverse life events - loss of loved one, neglect, sexual abuse, divorce, unemployment etc

Question 27

1. What are the 3 core symptoms of depression? | 2. What are the 7 associated symptoms of depression?

Answer 27

1. low mood; anhedonia; fatiguability ``` 2. disturbed sleep poor concenctration low self confidence appetite changes suicidal ideation psychomotor agitation/retardation guilt/self blame ```

Question 28

What is the ICD-10 classification of: 1. Mild depression 2. Moderate depression 3. Severe depression

Answer 28

1. 2 core symptoms + 2 associated symptoms 2. 2 core symptoms + 3 associated symptoms 3. 3 core symptoms + 4+ associated symptoms

Question 29

What is the characteristics of psychotic features in depression?

Answer 29

mood congruent (i.e. have a depressive theme)

Question 30

What are the clinical features of atypical depression?

Answer 30

- mood reactivity - mood brightens to positive events - increased appetite - increased sleep - interpersonal rejection sensitibity

Question 31

How may a patient with LD present with depression?

Answer 31

- loss of interest - change in behaviour - reduced energy - slowed activity - loss of appetite - self harming/challenging behaviours

Question 32

1. Which antidepressants are preferred in mixed anxiety-depression 2. which antidepressants should be avoided if there is a high suicide risk?

Answer 32

1. SSRIs | 2. TCAs and MAOIs

Question 33

1. Name examples of SSRIs 2. Name examples of TCAs 3. Name examples of SNRIs

Answer 33

1. sertraline, fluoxetine, paroxetine, citalopram 2. amitryptiline, imipramine 3. venlafaxine, duloxetine

Question 34

What is the MOA of mirtazepine?

Answer 34

Enhances noradrenergic and serotinergic neurotransmission but has no significant effect on the reuptake of monoamines

Question 35

When is ECT indicated for depression?

Answer 35

- treatment of choice in severe, life-threatening depressive illness, particularly when psychotic symptoms - essential treatment with the patient is dangerously suicidal and when a rapid resolution is required

Question 36

What is dysthymia?

Answer 36

mild chronic depressive symptoms that are not sufficiently severe to meet the criteria for mild depressive disorder.