What is an affective disorder? Give some examples.
An affective disorder is one where the mental state or function is affected by mood. The problem can be elevated mood or low mood.
- Depression
- Mania
What are the 3 main classification systems for categorising mood disorders?
- ICD-10 shows a description of the disorder
- DSM-5 gives specific operationalised diagnosis
- ICD-11 will adopt a dimensional approach with specifiers for specific traits
Define Depression
An emotion within the range of normal experience – a state of feeling, or mood, that can range from normal experience to severe, life-threatening illness.
It must last for at least 2 weeks with no hypomanic or manic episodes in lifetime. Not attributable to psychoactive substance use or organic mental disorder.
If the patient has psychotic symptoms or stupor then it is severe depression with psychotic symptoms. Need to exclude other psychotic illnesses first like schizophrenia.
What is Dysthymia?
A lower level of depression that isn’t severe enough in the patient’s eyes to interfere with their life i.e they can still work etc
In Major/ clinical Depression, how long does a typical episode last for?
4-6 months
4 key thinks to look for when diagnosing depression or mania
- Persistence of symptoms – at least 2 weeks
- Pervasiveness of symptoms – lasting symptoms i.e have them for most of the day
- Degree of impairment – unable to carry out tasks of normal, everyday life?
- Presence of specific symptoms or signs – occurs in 3 spheres
- Psychological
- Physical
- Social
What are some psychological symptoms of depression?
- Changes in mood
- Depression - presence of sadness not just absence of happiness. May show diurnal variation i.e worse in the morning or night
- Anxiety - inability to relax
- Perplexity - overwhelmed - common in puerperal illness (post-natal)
- Anhedonia – inability to experience pleasure in the things you would normally enjoy
- Changes in thought content
- Guilt – that isn’t merited/deserved
- Hopelessness
- Worthlessness
- Any neurotic symptomatology – hypochondriasis, agoraphobia, obsessions and compulsions, panic attacks
- Ideas of reference
- Delusions and hallucinations if severe - psychotic symptoms
Physical symptoms of depression (7)
- Lack of energy - fatigue
- Sleep disturbance
- Appetite changes – weight loss
- Libido
- Constipation
- Pain
- Change in psychomotor functioning
- Agitation - restless kind of anxiety
- Retardation – slowing down of things like thoughts, speech or movements
- Stupor – state of extreme retardation in which consciousness is intact. Patient stops moving, eating, speaking, drinking etc but on recovery they can recall clearly the events which occurred whilst they were in this state.
Symptoms of depression relation to social sphere
- Loss of interests (anhedonia)
- Irritability
- Apathy
- Withdrawal, loss of confidence, indecisive
- Loss of concentration, registration and memory
What is somatic syndrome?
A type of depression characterised by specific cluster of symptoms:
- Anhedonia
- Lack of reaction to events/activity
- Sleep disturbance – wakening early morning (2 hrs before normal time) with worse symptoms in the morning
- Loss of libido
- Objective evidence of psychomotor agitation or retardation
- Loss of appetite
- Marked weight loss
ICD-10 diagnostic criteria for Mild depression
at least 2 from general and 2 from additional
ICD-10 diagnostic criteria for Moderate depression
At least 2 from the general criteria and 4 from the additional list (to give 6 or more)
ICD-10 diagnositic criteria for Severe depression
You must have all 3 from the left and at least 5 from the right
What things are involved in the treatment of depression?
- Anti-depressants – selective serotonin reuptake inhibitors
- Psychological treatments – CBT, IPT, family therapy
- Physical treatments
- Electroconvulsive therapy (good for people with severe treatment-resistance depression)
- Psychosurgery (not done frequently)
- Deep brain stimulation / vagus nerve stimulation (both rare)
How can you measure depression symptoms?
- Diagnosis
- SCID – structured clinical interview for DSM disorders
- SCAN – schedules for clinical assessment in neuropsychiatry
- HDRS (Hamilton Depression Rating Scale)
- BDI-II (Beck Depression Inventory II)
- HADS (Hospital Anxiety and Depression Scale)
- PHQ-9 (Patient Health Questionnaire 9)
Define Mania
A term to describe a state of feeling, or mood, that can range from near-normal experience to something that is severe / life threatening. It is typically considered as a form of pathological, inappropriate elevated mood.
Those who experience mania do not complain of it as a symptom. It is often associated with loss of judgment, grandiose ideas, disinhibition, with similarities to the mental effects of stimulant drugs such as Cocaine.
Hypomania - ICD-10
- What is it?
- Symptoms?
- Diagnosis?
- A lesser degree of mania (mild elevation of mood) where there is no psychosis.
- Increased energy and activity, marked feeling of wellbeing, increased sociability, talkativeness, overfamiliarity, increased sexual energy, decreased need for sleep. May be irritable. Concentration reduced, new interests, mild overspending. It is not to the extent of severe disruption of work or social rejection
- To diagnose it as hypomania it has to have lasted for several days.
Mania
- Symptoms?
- Diagnosis?
- Elevated mood, +/- psychosis, increased energy, overactivity, pressure of speech, decreased need for sleep. Disinhibition, grandiosity, alteration of senses. Extravagant spending. Can be irritable rather than elated. Severe enough to disrupt ordinary work and social activities more or less completely.
- Must have had symptoms for at least 1 week to diagnose Mania
Which tool is used to measure the change in severity of Mania symptoms over time?
Young Mania Rating Scale (YMRS)
Treatment options for Mania?
- Antipsychotics
- Olanzapine
- Risperidone
- Quetiapine
- Mood stabilisers
- Sodium valproate
- Lamotrigene
- Carbamazepine
- Lithium
- Electroconvulsion therapy
What do you have to disclude when diagnosing mania?
Psychiatric
- Mixed affective state
- Schizoaffective disorder
- Schizophrenia
- Cyclothymia
- ADHD
- Drugs and Alcohol
Medical
- Stroke, MS, Tumour, epilepsy, AIDS, Neurosyphilis
- Endocrine – Cushing’s, hyperthyroidism
- SLE
ICD-10 diagnostic criteria for Bipolar Disorder?
To be diagnosed with Bipolar Affective Disorder you have to have had repeated (2+) episodes of depression and mania or hypomania.
- If no mania or hypomania present then the diagnosis is recurrent depression.
- If no depression the diagnosis is hypomania or bipolar disorder (as mania rarely appears as a one off episode and likely progresses to BD it is sufficient to diagnose biopolar disease from onset of mania - DSM-5)
Epidemiology of Bipolar Disease
Lifetime prevalence rate per 100 range between 0.7-1.6 – this is similar in industrialised and non-industrialised nations and between men and women.
Early age of onset – almost always <20
Onset can be earlier if positive FH – considered to have a genetic link
No differential prevalence according to income, occupation or educational status
How long can a manic episode last?
1-3 months
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Anti-psychotic drugs29
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Anti-depressants and Anxiolytics34
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Mood-stabilisers18
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Schizophrenia22
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Affective disorders24
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Anxiety disorders21
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Learning disabilities19
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Basic science of Substance Abuse15
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Clinical aspects of substance misuse31
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Organic mental disorders27
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Psychiatric problems in the general hospital12
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Old age psychiatry27
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Eating disorders21
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Child/adolescent psychiatry23
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Child psychiatry: school + early development19
