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Mood Disorders Flashcards

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1
Q

What are the features of somatic syndrome

A
  • markedly reduced appetite
  • weight loss
  • early morning wakening
  • diurnal variation in mood
  • psychomotor retardation
  • loss of libido
  • marked anhedonia
  • lack of emotional reactivity
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2
Q

Describe some of the psychotic symptoms that can occur in depression with psychosis

A

Delusions: mood congruent usually
Worthlessness: guilt, ill health, poverty, imminent disaster
Nihilistic delusions
Persecutory delusions

2nd person auditory hallucinations
Olfactory hallucinations eg rotting flesh

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3
Q

What % of those with depression will die by suicide

A

5-15%

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4
Q

What is the treatment for mild / moderate depression

A

Low intensity psychological interventions
Medication: 1st line treatment would usually be an SSRI eg citalopram, sertraline, fluoxetine or paroxetine

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5
Q

What is the treatment for moderate / severe depression (depression that has failed to respond to treatment)

A

Medication
High intensity psychological interventions
Consider secondary care referral

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6
Q

What is the treatment for severe depression with life threatening presentations and severe self neglect

A

Medication
High intensity psychological interventions
ECT
Crisis resolution and home treatment
MDT
Inpatient

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7
Q

How is relapse of depression prevented

A

Continued pharmacotherapy for 6 months after a depressive episode
Then continued pharmacotherapy for 2 years to reduce risk of relapse from recurrent depression

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8
Q

What are symptoms of hypomania

A

Mild elevation or mood instability
Increased energy
Mild overspending
Increased sociability and overfamiliarity
Distractability
Increased sexual energy
Decreased need for sleep

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9
Q

How to confirm a diagnosis of hypomania

A

Symptoms need to have been present for 4 days

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10
Q

What are the symptoms of mania

A

Elevated mood, expansive, irritable
Increased activity
Reckless behaviour
Disinhibition
Marked Distractability
Markedly increased sexual energy
Sleep impaired or absent
Grandiosity
Flight of ideas

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11
Q

How is a diagnosis of mania confirmed

A

Symptoms need to have been present for a week or have to be severe enough to necessitate inpatient admission

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12
Q

How can bipolar affective disorder be diagnosed

A

When there has been 2 episodes of mania or one episode of mania and one of depression

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13
Q

Describe the epidemiology of bipolar affective disorder

A

1% lifetime risk
Equal prevalence in men and women
Onset generally late teenage to early 20s

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14
Q

Aetiology of bipolar affective disorder

A

Genetics

Life events: prolonged stressful circumstances can predispose episodes

Substance misuse

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15
Q

Describe the prognosis of bipolar affective disorder

A

Average length of a manic episode is 6 months

Following this, at least 90% will have a further episode of mood disturbance

On average 10 episodes of mood disturbance over 25 year period

Less than 20% have a 5 year period of clinical stability

20-30x more likely to die by suicide than the general population

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16
Q

Common causes of bipolar relapse

A

Non concordance with medication
Life events, social stressors
Disruption of circadian rhythm
Substance misuse
Childbirth
Natural course of the illness

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17
Q

What is encephalitis

A

Neurological disorder caused by brain inflammation
Usually infective cause
5-10/100,000 per year

Non infective causes are often autoimmune and can mimic infective presentations as well as other neurological and psychiatric presentations

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18
Q

What investigations would you do for encephalitis

A

Clinical history
General and neurological examination
Routine blood and CSF analysis
Neuro imaging
EEG
Antibody testing

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19
Q

What is autoimmune limbic encephalitis

A

Medial temporal lobe involvement
Sub acute onset (3mos)
Altered mental state, cognitive dysfunction, seizures

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20
Q

What is acute disseminated encephalomyelitis

A

Often post infective and in the under 40s
Multi focal neurological deficits
Variable encephalopathy

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21
Q

What is anti NMDA receptor encephalitis

A

Predominantly affects the young and female
Psychosis, delusions, agitation, aggression, catatonia, seizures, irritability, insomnia, dysarthria, cognitive impairment, decreased levels of consciousness

Abnormal EEG

Positive antibody tests

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22
Q

What is bickerstaff encephalitis

A

Impairment of consciousness, ataxia and opthalmoparesis
Post infective

Often Monophasic with a good prognosis

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23
Q

What is autoimmune psychosis

A

Recently been recognised that isolated psychotic presentations often test positive for neuronal antibodies (anti NMDA receptor antibodies)

Psychiatric disturbance with neurological features

  • acute inset
  • neurological signs
  • adverse response to antipsychotics
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24
Q

Epidemiology of depression

A

Recurrent depressive disorder carries a lifetime risk of 10-25% in woman, 5-12% in men
2:1 F to M ratio
Late 20s avg onset
0.1% require admission

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25
Biological causes of depression
Genetic predisposition: 40-50% MZ twin concordance Chronic disease: pain, cancer, heart disease Hormonal changes: post partum depression
26
Psychological causes of depression
Negative thinking style Personality type: increased risk with neuroticism
27
Social causes of depression
Chronic stress Substance misuse Parenteral separation in childhood Social isolation Adverse life events
28
Describe the pathophysiology of depression
Neurochemistry: HPA axis Overactivity and monoamine deficiencies Neuroanatomy: recurrent early onset depression is associated with decreased size of hippocampus, amygdala and some frontal cortex areas
29
What are the 3 core symptoms of depression
Depressed mood - varies little from day to day and is unresponsive to circumstances Markedly reduced interest in almost all activities - loss of ability to derive pleasure from formerly enjoyed activities Lack of energy - leading to decreased activity
30
Biological symptoms of depression
Early wakening Diurnal variation in mood - mood typically worse in the morning Loss of appetite with unintentional weight loss Psychomotor retardation or agitation Loss of libido
31
What are cognitive symptoms of depression
Reduced concentration / memory Poor self esteem / worthlessness Guilt Hopelessness Suicide / self harm
32
Psychotic symptoms of depression
Delusions and hallucinations are both generally mood congruent Akinesis can be present Nihilistic delusions: patient doesn’t believe in concept of life - may think world has ended and its all one dream Cotard’s syndrome - patient may believe they are dead
33
What is the psychological approach to management of depression
1st line for mild depression and 1st like in combination with antidepressants for mild - moderate depression CBT is first line
34
What is the biological approach to management of depression
Antidepressants are recommended in mild - moderate or moderate - severe depression that has not responded to psychological interventions. SSRIs usually first line Lithium or atypical antipsychotics in resistant cases ECT in severe, resistant cases
35
What is the social approach to management of depression
Avoidance of alcohol, health eating, regular exercise, good sleep hygiene Support with education, work, finances, housing and social inclusion Help with access to benefits and housing Consider how carers are coping
36
Describe the prognosis of depression
Without treatment a first episode will generally remit within 6 months - 1 yr 60% recovery by 1 year, 80% will go on to have a further depressive episode Chronic depression occurs in 10-25%
37
What is a depressive episode
Must have 2 of the core symptoms of depression for at least 2 weeks + 2 biological or cognitive symptoms
38
What is recurrent depressive disorder
When a patient with a depressive episode goes on to have a further depressive episode Avg number of episodes experienced is 5
39
What is dysthymia
Chronically depressed mood that has its onset in early adulthood and may retain throughout the patients life with periods of wellness in between Mood is not severe enough to satisfy the criteria for a depressive episode and doesn’t present as discrete episodes Does not have severe effects on patients ability to function
40
How much is suicide risk increased in someone presenting with self harm
100x
41
Epidemiology of suicide
Elderly Male Homosexual / transgender Unmarried / unemployed Lives alone / social isolation Low socioeconomic status Farmer, nurse, doctor
42
Clinical risk factors of suicide
Psychiatric illness (highest in anorexia and depression) Physical illness Alcohol dependence Previous self harm FH of depression, alcoholism, suicide
43
What are some immediate management considerations after a suicide attempt
1. Is inpatient care required to preserve patient safety 2. Would the patient benefit from the input of home treatment / crisis team 3. Do they have existing social support that can be called upon 4. Is it possible to reduce means of self harm
44
What are some long term management considerations after a suicide attempt
Treat underlying psychiatric illness Optimise social functioning Crisis planning
45
What are the 2 types of bipolar affective disorder
Type I: experience manic episodes and major depression Type II: experience hypomania and major depression, absence of manic episodes
46
What is the epidemiology of bipolar affective disorder
1% lifetime risk Avg age of onset = 20 M=F
47
Aetiology of bipolar
MZ concordance 65-80% 1st degree relatives have a 7x increased risk of bipolar The most important environmental risk factor is child birth 50% risk of mania post partum in those with untreated bipolar
48
Biological features of bipolar affective disorder
Decreased need for sleep Increased energy Actions can become repetitive and lead to manic stupor Excessive Overactivity can lead to physical exhaustion, dehydration and death
49
Cognitive features of bipolar affective disorder
Elevated self esteem / grandiosity that can lead to delusions of grandeur Poor concentration Accelerated thinking Impaired judgement
50
Psychotic features of bipolar affective disorder
Disordered thought form Abnormal beliefs Perceptual disturbances
51
Features of hypomania
Mild elevation of mood / irritability Increased energy, decreased sleep Mild overspending / risk taking Distractability Increased sexual energy
52
Features of mania
Generally requires hospital admission Significantly elevated mood Highly active, little to no sleep Reckless decisions Grandiosity
53
Describe the biological management of mania
Antidepressants discontinued Benzodiazepines can help in reducing severe behavioural disturbances Anti manic agent started (risperidone, olanzapine, quetiapine, lithium, valproate)
54
Describe the psychological / social management of mania
Psychoeducation once the patient is more stable in mood Creation of a non stimulatory environment
55
Describe the biological management of acute depression in bipolar
Consider increasing mood stabiliser dose SSRI can be co-prescribed but should be gradually discontinued once the patient has been in remission for 8 weeks - antidepressants are thought to increase the manic risk so should always be given with a mood stabiliser
56
Describe the psychological / social management of acute depression in bipolar
High intensity CBT and Psychoeducation Identify and nullify social stressors
57
Describe the long term biological management of bipolar
Lithium, valproate or olanzapine based on sex, comorbidity and patient preference All are teratogenic If one is ineffective consider switching to another
58
Long term psychological / social management of bipolar
Psychoeducation to recognise early signs of relapse CBT may be used Avoidance of known episode precipitants Support for education, finance, housing
59
Describe the prognosis of bipolar affective disorder
Untreated a patient will have 8-10 manic / depressive episodes over their lifetime Following a manic episode there is a 90% chance of further episodes Rapid cycling (>4 events per year) is associated with poor prognosis Depressive episodes are more common than manic
60
What is relapse of bipolar associated with
Non concordance to lithium Life events Circadian rhythms Disruption Childbirth Substance abuse
61
Side effects of lithium
GI upset Dry mouth Metallic taste
62
Limitations of lithium
Narrow therapeutic range Requires regular blood tests to monitor plasma level Not suitable in renal impairment as is renally excreted Serum concentration can be increased by thiazides, ACEIs and NSAIDs Not suitable for those with cardiovascular disease Not suitable for those with thyroid disease
63
What are the neurological, renal and CV effects of lithium toxicity
Neuro: tremor, seizures, delirium, coma Renal: AKI, nephrotic syndrome, diabetes insipidus CV: QT prolongation, sinus node dysfunction
64
What is used to treat severe lithium toxicity with neurological symptoms
Urgent haemodialysis
65
MOA of valproate as a mood stabiliser
Na channel blocker Increases GABA levels
66
Side effects of valproate
Weight gain Sedation Hair loss Tremor Blood dyscrasias Liver failure
67
What is cyclothymia
Analogous to dysthymia Begins in early adulthood and follows a chronic course with intermittent periods of wellness Instability of mood that is not severe enough to meet threshold for bipolar diagnosis
68
Characterisation of borderline personality disorder
Intense emotions which can change quickly, difficulties with relationships, feelings of emptiness, fears of abandonment, impulsive behaviour and self harm
69
Order of NICE recommendations for depression
1. Guided self help 2. Group CBT 3. Group behavioural activation 4. Individual CBT 5. Individual behavioural activation, 6. Group exercise 7. Group mindfulness and meditation 8. Interpersonal psychotherapy
70
What should be done before a patient starts ECT treatment
Antidepressant medication should be reduced but not stopped
71
What can selective serotonin reuptake inhibitor discontinuation syndrome present with
Diarrhoea Vomiting Abdominal pain
72
What is procyclidine used for
Acute dystonia secondary to antipsychotics
73
What is conversion disorder
Loss of motor or sensory function Mostly caused by stress
74
How is hypomania different to mania
Hypomania is elevated mood, pressured speech and flight of ideas without any psychotic symptoms
75
Next step of symptoms of hypomania in primary care
Routine referral to community mental health team
76
What is clang associations (speech)
Flight of ideas where the ideas are related only by rhyme or being similar sounding
77
How does depression differ from dementia
Depression can cause memory loss due to lack of concentration Dementia progresses much more slowly and takes time for patients to notice the symptoms. Usually others notice the symptoms not the patient themselves and the patient is not usually worried about memory loss

Psychiatry (6 decks)

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