Mood disorders Flashcards
1
Q
Define euthymic
A
Normal mood
2
Q
Define hyperthymic
A
Elevated mood
3
Q
Define cyclothymic
A
Variable mood
4
Q
What is sanguine?
A
Extorvert
5
Q
What is phlegmatic?
A
Self content, kind
6
Q
What is melancholic?
A
Perfectionist, worrier
7
Q
What is choleric?
A
Leaders, in charge
8
Q
Define anhedonia
A
Loss of enjoyment / pleasure
9
Q
Define anergia
A
Lack of energy
10
Q
Define amotivation
A
Lack of motivation
11
Q
What is classed as early morning wakening?
A
Waking at least 2 hours before the expected / normal waking time
12
Q
What is psychomotor retardation?
A
Subjective or objective slowing of thoughts and or movement
13
Q
What is stupor?
A
The absence of relational functions i.e. action and speech
14
Q
Describe appearance and behaviour in depression
A
- reduced facial expression
- brow is classically ‘furrowed’
- reduced eye contact
- limited gesturing; movements may be slow or absent
- rapport is often difficult to establish
15
Q
Describe speech in depression
A
- reduced rate of speech
- lowered in pitch
- reduced in volume (speech is quiet)
- reduced intonation (speech is monotonous)
- increased speech latencies (longer time between end of a question and them starting to speak)
- limited content (answers are often short, brief and unembellished)
16
Q
What is mood?
A
A prolonged prevailing state of disposition, typically associated with what the patient describes (i.e. subjective)
‘how do you feel’
e.g. low, down, flat, empty, black
17
Q
What is affect?
A
In essence, its mood applied to things (events, people, etc). when taking a history its how the patients feelings change in relation to their surroundings and the context; its something that you typically observe or infer (i.e. objective)
How the patient reacts
e.g. depressed, reduced range, limited reactivity
18
Q
Describe thought in depression
A
- form; typically normal
- flow; thoughts are slowed, pondering, can be almost absent (subjectively or objectively)
- content; negative, self accusatory, failure, guilt, low self esteem, pessimism, delusions can occur (guilt, poverty, nihilism, hypochondriasis), suicidal thinking is common
19
Q
Describe perception in depression
A
- in most cases, there is no perceptual disturbance
- some people report increased self-referential thinking ‘people are talking about me’
- hallucinations can occur; secondary and almost always auditory, derogatory ‘you are a bad person, you deserve to die’, typically reflect negative and depressive themes; its as if the voices reflect the depressive content
20
Q
Describe cognition in depression
A
- subjectively, cognition is slow with complaints of poor memory (probably more to do with inattention)
- pseudo-dementia
- typical deficits involve working memory, attention and planning
- often compounded by anxiety
21
Q
Describe insight in depression
A
- in contrast to disorders such as schizophrenia and mania, insight in depression is typically preserved
- people are usually aware of their symptoms, recognition is commonly intact
- however, attribution can often be affected by the illness - symptoms may be blamed on sins, physical illness, personal failing or weakness
22
Q
Name the affective mood disorders as classified in ICD-10
A
- mania
- bipolar disorders
- depressive disorder
- dysthymia
23
Q
Describe the general criteria for depression
A
- the depressive episode should last at least 2 weeks
- there have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode at any time in the individuals life
- at least 2/3 of core features
- at least 4 of the additional symptoms
24
Q
Name the core features in which at least 2/3 must be present for diagnosis of depression
A
- depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks
- loss of interest or pleasure in activities that are normally pleasurable
- decreased energy or increased fatigability
25
Name the additional features of depression in which at least 4 must be present for diagnosis
- loss of confidence or self esteem
- unreasonable feelings of self-reproach or excessive and unreasonable guilt
- recurrent thoughts of death or suicide, or any suicidal behaviour
- complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation
- change in psychomotor activity, with agitation or retardation (either subjective or objective)
- sleep disturbance of any type
- change in appetite (decrease or increase) with corresponding weight change
26
How do you differentiate between moderate and severe depression?
- moderate depressive episode; two core symptoms + four additional symptoms, total of at least 6
- severe depressive episode; all 3 core symptoms + 5 others, to give a total of at least 8
- HRSD and MADRS or BDI scales can be used for assessment
27
Somatic syndrome is a subtype of depression, name the symptoms
- at least 4 should be present
- marked loss of interest or pleasure in activities that are normally pleasurable
- lack of emotional reactions to events or activities that normally produce an emotional response
- waking in the morning 2 hours or more before the usual time
- depression worse in the morning
- objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people)
- marked loss of appetite
- weight loss (5% or more of body weight in the past month)
- marked loss of libido
28
Describe the symptoms atypical depression
- mood reactivity (that is, mood brightens in response to actual or potential positive events)
Two or more of the following;
- significant weight gain or increase in appetite
- hypersomnia
- leaden paralysis (that is, heavy, leaden feelings in arms or legs)
- long standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
29
What is cotards syndrome?
Cotard's delusion, also known as walking corpse syndrome or Cotard's syndrome, is a rare mental disorder in which the affected person holds the delusional belief that they are dead, do not exist, are putrefying, or have lost their blood or internal organs.
30
What are the five 'R's in depression disease course?
- response
- remission
- relapse
- recovery
- recurrence
31
Describe bipolar affective disorder as defined in ICD-10
A disorder characterised by two or more episodes in which the patients mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of hypomania or mania, and on others, depression. Repeated episodes of hypomania or mania only are classified as bipolar
32
What is hypomania?
A level of disturbance below mania
33
Name the symptoms of a hypomanic episode
- the mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days.
At least three of;
- increased activity or physical restlessness
- increased talkativeness
- difficulty in concentration or distractibility
- decreased need for sleep
- increased sexual energy
- mild spending sprees, or other types of reckless or irresponsible behaviour
34
Name the symptoms of a manic episode
- mood must be predominantly elevated, expansive or irritable and definitely abnormal for the individual concerned, must be prominent and sustained for at least 1 week
At least three of;
- increased activity or physical restlessness
- increased talkativeness
- flight of ides or the subjective experience of thoughts racing
- loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances
- decreased need for sleep
- inflated self esteem or grandiosity
- distractibility or constant changes in activity or plans
- behaviour which is foolhardy or reckless and whose risks the subject does not recognise
- marked sexual energy or sexual indiscretions
35
Describe appearance and behaviour in mania
- bright clothes
- distractibility
- loss of normal social inhibitions / overfamiliarity
36
Describe speech in mania
- increased talkativeness, hard to interrupt
| - punning and clang associations
37
Describe thoughts in mania
- increased flow (lots of thoughts)
- flight of ideas and loosening of associations
- grandiosity
38
Describe mania without psychotic symptoms
The absence of hallucinations or delusions, although perceptual disorders may occur (e.g. subjective hyperacusis, appreciation of colours as specially vivid etc)
39
Describe mania with psychotic symptoms
- delusions or hallucinations are present, other than those listed as typical schizophrenic (i.e. delusions other than those that are completely impossible or culturally inappropriate and hallucinations that are not in the third person or giving a running commentary)
- the commonest examples are those with grandiose, self-referential, erotic or persecutory content
40
Describe the onset of bipolar disorder
- onset usually in late teens, or early 20s, approximately 10 years earlier than unipolar depression
- a family history of BPAD often results in earlier onset and episodes are precipitated by lower levels of stress
- there is often a delay between first presentation and diagnosis
- onset after the age of 60 is rare and is often associated with treatment resistance, progressive decline in functioning, and an underlying organic cause
41
Describe the differences between bipolar 1 and bipolar 2
- bipolar 1; not just mania, most people will have had episodes of major depression
- bipolar 2; depression and hypomania
42
The appetitive / approach systems in the brain function to do what and name contributing areas
- function to mediate seeking and approach behaviours (including pleasure)
- ascending dopamine systems; mesolimbic / cortical projection
- ventral striatum
- dorsal striatum (movement)
- amygdala (conditioning / learning)
- anterior cingulate (attention / conflict / response selection)
- orbitofrontal cortex (relative reward preference / rule learning)
43
The aversive / defensive systems in the brain function to do what and name contributing areas
- function to promote survival in event of threat (fear / pain)
- ascending serotonin systems
- NA/ CRF/ peptide transmitters
- central nucleus of amygdala
- hippocampus
- ventroanterior and medial hypothalamus
- periaqueductal grey matter
44
What is the role of the amygdala?
Emotion, fear
45
What is the role of the hippocampus?
- learning
- cognition
- anxiety
- HPA axis
- other vegetative functions
46
What is the function of the prefrontal cortex?
- working memory
- cognition
- mood
47
Name the four commonly used scales to measure mood disorders
- inventory of depressive symptomatology; self report, 30 item patient rated scale, very detailed (IDS-30-SR)
- quick inventory of depressive symptomatology self report 16 (QIDS)
- hospital anxiety and depression scale; 14 item self rated scale
- montgomery-asberg rating scale (MADRS); 10 item observer rated scale, highly sensitive to change
48
Name the 'top 4' antidepressants
- escitalopram; SSRI
- sertaline; well established, has a good cardiac profile and allows easy dose titration
- mitrazepine; promotes sleep and appetite / weight gain, less likely to cause nausea or sexual side effects
- venlafaxine; associated with a higher rate of adverse effects but shows a dose response relationship and may be slightly more effective
49
Describe relapse prevention in depression
- after first episode; continue antidepressant for at least 6 months after full recovery without reducing dose
- second episode or more; continue antidepressant for at least 1-2 years after full recovery without reducing dose
50
Describe the principles of acute mania / hypomania treatment
- maximise antimanic dose if patient already of maintenance treatment
- antidepressants should be discontinued
- combination therapy may be required
- hospital admission likely to be required if mania
51
Describe the treatment of acute mania
- antipsychotic is first line; olanzipine, quetiapine or risperidone
- other options; lithium, valporate, carbamazepine, ECT
- medication should be oral if possible
- benzodiazepines or Z-drugs can be used for symptoms control e.g. agitation and insomnia
52
Describe the treatment principles of acute bipolar depression
- antidepressants should not be prescribed without an antimanic drug
- avoid antidepressants in those with a recent manic / hypomanic episode or history of rapid cycling
- SSRI|s (particularly fluoxetine) preferable to other classes
53
Describe the treatment of bipolar depression
- antipsychotic is first line; evidence base for quetiapine, olanzapine or lurasidone
- antidepressants can be used alongside antipsychotic, lithium or valporate (to prevent mania)
- lamotrigine can be used but takes time to titrate
- ECT
- lithium
54
What is the gold standard long term treatment for bipolar maintenance?
Lithium
55
What needs monitored in patients on lithium?
- lithium level
- U and Es
- ECG
- TFTs
- calcium
56
How is ECT given?
- usually given twice weekly in the UK
- most are inpatients
- majority receive bilateral, but can also be unilateral (non-dominant hemisphere, usually right unilateral)
- always under general anaesthetic with a muscle relaxant
- dose of electricity is titrated for each patient to receive a seizure typically lasting 15-30 seconds
- seizure is monitored visually and with EEG
- can be stopped with benzodiazepines if prolonged
57
Name side effects of ECT
- 66% of patients complain of at least one side effect, usually mild and self limiting and respond to symptomatic treatment
- headache
- memory problems
- cognitive problems
- muscle aches
- confusion
- nausea
58
Describe the cognitive side effects of ECT
- 64% of patients experience some form of memory problem
- memory loss is autobiographical and most accentuated for the time period closest to treatment
- ability to learn new information and non-cognitive memory domains are not affected
- the majority of patients report an improvement in cognitive function at two months post treatment
59
What are the main effects of ECT on the CNS?
- modulation of monoamines
- potent anticonvulsant effects
- second messenger system effect
- reduces hyperconnectivity in frontal and limbic circuits
- bolsters neuronal survival
- promotes production of new neuronal processes in areas involving cognitive and emotional funciton
60
Give examples of negative automatic thoughts
- overgeneralising
- dichotomous thinking; all or nothing, black or white
- selective abstraction; focus on on negative detail
- personalisation
- minimisation or magnification
- arbitrary evidence
- emotional reasoning
- shoulds and musts
61
Name the forms of psychotherapy
- behavioural activation
- cognitive behavioural analysis system of psychotherapy (CBASP)
- acceptance and commitment therapy
- psychoeducation
62
Describe the stress response
- amygdala acts as the emotional filter of brainfor assessing via the thalamus if material requires stress or fear response
- modified by later received cortically processed signal, here a series of responses to the stressor prior to adrenal gland releasing cortisol
- acute stress leads to dose dependent increase in catecholamines and cortisol
63
What are the biological (physical) symptoms of anxiety?
- sweating, hot flushes or cold chills
- trembling or shaking
- muscle tension or aches and pains
- numbness or tingling sensations
- feeling dizzy, unsteady, faint or lightheaded
- dry mouth (not due to medication or dehydration)
- feeling of choking
- a sensation of lump in the throat, or difficulty in swallowing
- difficulty breathing
- palpitations or pounding heart, or accelerated heart rate
- chest pain or discomfort
- nausea or abdominal distress
64
What are the cognitive symptoms of anxiety?
- fear of losing control
- feeling keyed up, on edge or mentally tense
- difficulty in concentrating
- feeling that objects are unreal (derealisation)
- feeling that the self is distant or 'not really here' (depersonalisation)
- hypervigilance
- racing thoughts
- meta-worry
- health anxiety
- beliefs about the importance of worry
- preference for order and routine
65
What are the behavioural symptoms of anxiety?
- avoidance of certain situations
- exaggerated response to minor surprises or being startled
- difficulty in getting to sleep because of worrying
- excessive use of alcohol / drugs
- restlessness and inability to relax
- persistent irritability
- checking behaviours
- seek reassurance from family / GP
66
Name the different types of anxiety disorder
- generalised anxiety disorder
- panic disorder
- agoraphobia
- social phobia
- specific phobia
- obsessive compulsive disorder
- PTSD
67
What is generalised anxiety disorder?
Anxiety that is generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is free floating. The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, light-headedness, palpitations, dizziness and epigastric discomfort. Needs to be severe enough to be; long lasting (most days for at least 6 months), not controllable, causing significant distress / impairment in function
68
Generalised anxiety disorder is typically associated with what symptoms?
- restlessness or feeling keyed up or on edge
- being easily fatigued
- difficulty concentrating or mind going blank
- irritability
- muscle tension
- sleep disturbance (difficulty falling or staying asleep, restless unsatisfying sleep)
69
What is the treatment of generalised anxiety disorder?
- cognitive behavioural therapy
- SSRIs / SNRIs
- pregabalin
- benzodiazepines (short term only)
70
What is panic disorder?
The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable
71
Describe the symptoms of panic disorder
- sudden onset of palpitations
- chest pain
- choking sensations
- dizziness
- feelings of unreality
- there is also a secondary fear of dying, losing control or going mad
72
When is the typical onset of panic disorder?
Late adolescence to mid-30s
73
When is the typical onset of generalised anxiety disorder?
20-40
74
Describe the treatment of panic disorder
- CBT
- SNRIs / SSRIs / tricyclics
- benzodiazepines (short term only)
75
What are the three types of phobias?
- agoraphobia
- social phobia
- specific phobia
76
What is agoraphobia?
A fairly well defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places or travelling alone in trains, buses or planes. Avoidance of the phobic situation is often prominent, and some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations
77
What is a specific phobia?
A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation, the patient recognises that the fear is excessive or unreasonable
78
Describe the treatment of specific phobias
- behavioural therapy; exposure, graded exposure / systematic desensitisation
- add in CBT if necessary
- SSRIs / SNRIs if required
79
What is social phobia / social anxiety disorder?
A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. Common anxiety symptoms are; blushing or shaking, fear of vomiting and urgency or fear of micturition or defecation
80
Describe the treatment of social phobia
- CBT
- SSRIs / SNRIs
- benzodiazepines (short term only)
81
Described the symptoms of obsessive compulsive disorder
Must be present most days for at least 2 weeks and be a source of distress and interfere with activities
Obsessional thoughts;
- ideas, images or impulses entering the mind in a stereotyped way
- recognised as the patients own thoughts
- unpleasant, resisted and ego-dystonic
Compulsive acts;
- repeated rituals or stereotyped behaviours
- not enjoyable
- not functional
- often viewed as 'neutralising'
- recognised as pointless
- resistance may diminish over time
82
Describe the treatment of OCD
- CBT, including response prevention
| - SSRIs / clomipramine
83
What are the core symptoms of anxiety disorders and what neural circuits are responsible for these?
```
Amygdala-centred circuit;
- panic
- phobia
Cortico-striatal-thalamic circuit;
- anxiety
- apprehension
- obsessions
```
84
The re-experiencing of traumatic memories in anxiety is governed by what brain area?
Hippocampus
85
The autonomic output of anxiety is governed by what brain area?
Locus coeruleus (increase in BP/HR)
86
The endocrine features of anxiety is governed by what brain area?
Hypothalamus (increase in cortisol)
87
The avoidance feature of anxiety is governed by what brain area?
Periaqueductal grey (fight / flight)
88
The affect of fear in anxiety is governed by what brain area?
Anterior cingulate cortex / orbitofrontal cortex
89
Name the neurotransmitters involved in amygdala centred circuits
- 5-HT
- GABA
- glutamate
- CRF (corticotrophin releasing factor)
- norepinephrine
- voltage gated ion channels
