Mood Disorders Flashcards
1
Q
What is the definition of mood?
What do patients with mood disorders experience?
Mood disorders have also been called….
A
- Mood - description of one’s internal emotional state
- Patients with mood disorders experience an abnormal range of moods and lose some level of control over them
- Mood disorders = affective disorders
2
Q
Mood disorders vs. Mood Episodes
A
-
Mood episodes
- Distinct periods of time in which some abnormal mood is present
-
Mood disorders
- Defined by patterns of mood episodes
- Some may have psychotic features (delusions or hallucinations)
3
Q
What are the 4 types of mood episodes?
A
- Major depressive episode
- Manic episode
- Mixed episode
- Hypomanic episode
4
Q
What are the 5 types of main mood disorders?
A
- Major depressive disorder (MDD)
- Bipolar I disorder
- Bipolar II disorder
- Dysthymic disorder
- Cyclothymic disorder
5
Q
How is Major Depressive Episode defined by DSM-IV criteria?
A
Must have at least 5 of the following symptoms (must have either #1 or #2) for at least a 2-wk period:
- Depressed mood
- Anhedonia (loss of interest in pleasurable activites)
- Change in appetite or body weight (increased or decreased)
- Feelings of worthlessness or excessive guilt
- Insomnia or hypersomnia
- Diminished concentration
- Psychomotor agitation or retardation (restlessness or slowness)
- Fatigue or loss of energy
- Recurrent thoughts of death or suicide
*symptoms must not be due to substance use or medical conditions, must cause social/occupational impairment*
6
Q
What is the acronym for symptoms of major depression?
A
SIG E CAPS
- Sleep
- Interest
- Guilt
- Energy
- Concentration
- Appetite
- Psychomotor activity
- Suicidal ideation
7
Q
A person who has been previously hospitalized for a major depressive episode has a ___% risk of commiting suicide later in life.
A
15%
8
Q
How is Manic Episode defined by DSM-IV criteria?
A
A period of abnormally & persistently elevated, expansive or irritable mood, lasting at least 1 wk and including at least 3 of the following (4 if mood is irritable)
- Distractibility
- Inflated self-esteem or grandiosity
- Increase in goal-directed activity (socially, at work, or sexually)
- Decreased need for sleep
- Flight of ideas or racing thoughts
- More talkative or pressured speech (rapid & uninterruptible)
- Excessive involvement in pleasurable activities that have a high risk of negative consequences (ex: buying sprees, sexual indiscretions)
*symptoms can’t be due to substance use or medical conditions, must cause social or occupational impairment, 75% of patients have psychotic symptoms*
9
Q
What is the acronym for symptoms of mania?
A
DIG FAST
- Distractability
- Insomnia
- Grandiosity
- Flight of ideas
- Activity/agitation
- Speech (pressured)
- Thoughtlessness
10
Q
What is the definition of a mixed episode?
A
- Criteria are met for both manic episode and major depressive episode
- These criteria must be present nearly every day for at least 1 week
- Psychiatric emergency
11
Q
What is the definition of a hypomanic episode?
A
Distinct period of elevated, expansive or irritable mood that includes at least 3 of the symptoms listed for the manic episode criteria (4 if mood is irritable)
12
Q
What are the fundamental differences between mania and hypomania?
A
-
Mania
- Lasts at least 7 days
- Causes severe impairment in social or occupational functioning
- May necessitate hospitalization to prevent harm to self or others
- May have psychotic features
-
Hypomania
- Lasts at least 4 days
- No marked impairment in social or occupational functioning
- Does not require hospitalization
- No psychotic features
13
Q
What are medical causes of a depressive episode?
A
- Cerebrovascular disease
- Endocrinopathies
- Cushing’s syndrome, Addison’s disease, hypoglycemia, hyper/hypothyroidism, hyper/hypocalcemia
- Parkinson’s disease
- Viral illness (mononucleosis)
- Carcinoid syndrome
- Cancer (lymphoma & pancreatic carcinoma)
- Collagen vascular disease (SLE)
14
Q
What are the medical causes of a manic episode?
A
- Metabolic (hyperthyroidism)
- Neurological disorders
- Temporal lobe seizures
- Multiple sclerosis
- Neoplasms
- HIV infection
15
Q
What are some causes of medication/substance-induced depressive episodes?
A
- EtOH
- Antihypertensives
- Barbiturates
- Corticosteroids
- Levodopa
- Sedative-hypnotics
- Anticonvulsants
- Antipsychotics
- Diuretics
- Sulfonamides
- Withdrawal from psychostimulants (cocaine, amphetamines)
16
Q
What are some causes of medication/substance-induced mania?
A
- Corticosteroids
- Sympathomimetics
- Dopamine
- Agonists
- Antidepressants
- Bronchodilators
- Levodopa
17
Q
What is the DSM-IV criteria for major depressive disorder?
A
- At least one major depressive episode
- No history of manic or hypomanic episode
18
Q
What is seasonal affective disorder?
A
- Subtype of MDD
- Major depressive episodes occur only during winter months (fewer daylight hours)
- Patients respond to treatment with light therapy
19
Q
Major depressive disorder
- Lifetime prevalence: ___%
- Average age of onset is ___
- Women vs. men?
- SES differences?
- Prevalence in elderly from ___ to ___%.
A
- Lifetime prevalence: 15%
- Average age of onset is 40
- 2x as prevalent in women than men
- No ethnic/SES differences
- Prevalence in elderly from 25-50%
20
Q
What are some sleep problems associated with major depressive disorder?
A
- Multiple awakenings
- Initial and terminal insomnia
- Hard to fall asleep and early morning awakenings
- Hypersomnia
- Rapid eye movement (REM) sleep shifted to earlier in night and stages 3 & 4 decreased
21
Q
What are 4 likely etiologies of major depressive disorder?
A
- Abnormalities of serotonin/catecholamines
- Other neuroendocrine abnormalities
- Psychosocial/life events
- Genetic predisposition
22
Q
Etiology of MDD
Abnormalities of serotonin & catecholamines
A
- Decreased brain & CSF levels of serotonin and its main metabolite 5-HIAA are found in depressed patients
- Abnormal regulation of beta-adrenergic receptors has also been shown
- Drugs that increase availability of serotonin, NE & dopamine often alleviate symptoms of depression
23
Q
Etiology of MDD
Other neuroendocrine abnormalities
A
-
High cortisol
- Hyperactivity of hypothalamic-pituitary-adrenal axis as shown by failure to suppress cortisol levels in dexamethasone suppression test
-
Abnormal thyroid axis
- Thyroid disorders associated w/ depressive symptoms
- 1/3 MDD patients who have otherwise normal thyroid levels show blunted response of TSH to infusion of TRH
24
Q
Etiology of MDD
Psychosocial/life events
A
- Loss of a parent before age 11 is associated with the later development of major depression
- Stable family and social functioning have been shown to be good prognostic indicators in the course of major depression
25
**Etiology of MDD**
Genetic predisposition
* 1st-degree relatives are 2-3x more likely to have MDD
* Concordance rate for monozygotic twins is about 50%, 10-25% for dizygotic twins
26
What is the typical course and prognosis of Major Depressive Disorder?
How many patients eventually commit suicide?
* If left untreated, depressive episodes are self-limiting but usually last from **6-13 months**
* Episodes occur more frequently as the disorder progresses
* Risk of subsequent episode is 50% within the first 2 yrs after the first episode
* About **15%** of patients eventually commit suicide.
27
How can medications be used to treat Major Depressive Disorder?
* Antidepressant medications signficantly reduce the length and severity of symptoms
* May be used prophylactically btwn major depressive episodes to reduce the risk of subsequent episodes
* 75% of patients are treated successfully with medical therapy
28
What are the 4 main treatment options for Major Depressive Disorder?
* Hospitalization
* Pharmacotherapy
* Psychotherapy
* Electroconvulsive therapy
29
When is hospitalization indicated for major depressive disorder?
Indicated if patient is at risk for suicide, homicide or is unable to care for self
30
What are the 3 categories of antidepressant medications?
* Selective serotonin reuptake inhibitors (SSRIs)
* Tricyclic antidepressants (TCAs)
* Monoamine oxidase inhibitors (MAOIs)
31
What are the side effects of SSRIs?
* Safer and better tolerated than other classes of antidepressants
* Side effects mild but include:
* Headache
* GI disturbance
* Sexual dysfunction
* Rebound anxiety
32
What are the side effects of TCAs?
* Most lethal in overdose
* Side effects
* Sedation
* Weight gain
* Orthostatic hypotension
* Anticholinergic effects
* Can aggravate prolonged QTC syndrome
33
What are the side effects of MAOIs?
* Useful for treatment of **refractory depression**
* Risk of **hypertensive crisis** when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, aged cheeses, liver, smoked meats)
* Risk of **serotonin syndrome** when used in combination with SSRIs
* Most common side effect: **orthostatic hypotension**
* Tyramine is an intermediate in the conversion of tyrosine to NE
34
What are 3 common adjuvant medications used for major depressive disorder?
Why are they used?
* **Stimulants** (methylphenidate)
* Terminally ill, patients w/ refractory symptoms
* Action rapid, but potential for dependence limits use
* **Antipsychotics**
* Patients w/ psychotic features
* **Liothyronine (T3), Levothyroxine (T4), lithium, L-tryptophan (serotonin precursor)**
* Convert nonresponders to responders
35
What type of psychotherapy is useful for major depressive disorder?
* Behavioral therapy
* Cognitive therapy
* Supportive psychotherapy
* Dynamic psychotherapy
* Family therapy
* May be used in conjunction with pharmacotherapy
36
When is electroconvulsive therapy indicated for MDD?
Is it safe?
* Indicated if:
* Patient is unreponsive to pharmacotherapy
* Patient cannot tolerate pharmacotherapy
* Rapid reduction of symptoms is desired (suicide risk, etc)
* ECT is safe and may be used alone or in combination with pharmacotherapy
37
How is ECT performed?
What is a common side effect?
* Premedication with **atropine**
* General anesthesia, admin of muscle relaxant
* **Generalized seizure induced**
* Passing current of electricity across the brain (unilateral or bilateral)
* Seizure lasts \<1 min
* 8 treatments administered over 2-3 week period, significant improvement often noted after 1st treatment
* Common SE: retrograde amnesia (disappears w/i 6 months)
38
What is Melancholic Depression?
* 40-60% of hospitalized patients with major depression
* Characterized by:
* Anhedonia
* Early morning awakenings
* Psychomotor disturbance
* Excessive guilt
* Anorexia
* Example: MDD with melancholic features
39
What is Atypical Depression?
* Characterized by:
* Hypersomnia
* Hyperphagia
* Reactive mood
* Leaden paralysis
* Hypersensitivity to interpersonal rejection
40
What is Catatonic Depression?
* Characterized by:
* Catalepsy (immobility)
* Purposeless motor activity
* Extreme negativism or mutism
* Bizarre postures
* Echolalia
* May also be applied to bipolar disorder
41
What is Psychotic Depression?
* 10-25% of hospitalized depressions
* Characterized by:
* Delusions
* Hallucinations
42
Bipolar I disorder is traditionally known as....
Manic Depression
43
What is the DSM-IV Criteria for Bipolar I Disorder?
* Only requirement is the occurence of one manic or mixed episode
* 10-20% of patients experience only manic
* May be interspersed euthymia, major depressive episodes, dysthymia or hypomanic episodes (but none required for diagnosis)
44
**Bipolar Disorder I**
* Lifetime prevalence: \_\_\_%
* Women vs. men
* Ethnic differences?
* Onset usually before age \_\_\_
* Lifetime prevalence: 1%
* Women and men equally affected
* No ethnic differences seen
* Onset usually before age 30
45
What factors contribute to the etiology of Bipolar I?
What is the difference in family members?
* Biological, environmental, psychosocial and genetic factors are all important
* 1st degree relatives of patients with bipolar disorder are 8-18x more likely to develop the illness
* Concordance rates
* Monozygotic twins: 75%
* Dizygotic twins: 5-25%
46
How long do untreated manic episodes last?
What is the typical course?
* Untreated manic episodes generally last about 3 months
* Course usually chronic w/ relapses
* As disease progresses, episodes may occur more frequently
* Only 7% of patients do not have a recurrence of symptoms after their 1st manic episode
47
What is the prognosis of Bipolar I?
What is used for prophylaxis?
* Worse prognosis than MDD
* Only 50-60% of patients treated w/ lithium experience significant improvement in symptoms
* **Lithium** prophylaxis btwn episodes helps to decrease the risk of relapse
48
What are the 3 treatment options for Bipolar I disorder?
* Pharmacotherapy
* Psychotherapy
* ECT
49
What type of pharmacotherapy is used to treat Bipolar I disorder?
* **Lithium**
* Mood stabilizer
* **Anticonvulsants** (carbamazepine, valproic acid) & **mood stabilizers**
* Useful for rapid cycling bipolar disorder & mixed episodes
* **Olanzapine**
* A typical antipsychotic
50
What type of psychotherapy is used for Bipolar I?
* Supportive psychotherapy
* Family therapy
* Group therapy (once the acute manic episode has been controlled)
51
What is the usefulness of ECT in Bipolar I?
* Works well in treatment of manic episodes
* Usually requires more treatments than for depression
52
What is "rapid cycling"?
Occurrence of 4 or more mood episodes in 1 year
53
What are the side effects of lithium?
* Weight gain
* Tremor
* GI disturbances
* Fatigue
* Arrhythmias
* Seizures
* Goiter/hypothyroidism
* Leukocytosis (benign)
* Coma
* Polyuria
* Polydipsia
* Alopecia
* Metallic taste
54
Bipolar II disorder is alternatively called...
recurrent major depressive episodes w/ hypomania
55
What is the DSM-IV criteria for Bipolar II disorder?
* Hx of one or more major depressive episodes and at least one **hypomanic** episode
* If there has been a full manic episode _even in the past_, then the diagnosis is _not_ bipolar II disorder, but bipolar I
56
**Bipolar II Disorder**
* Lifetime prevalence: \_\_\_%
* Women vs. men
* Onset usually before age \_\_\_
* Ethnic differences?
* Lifetime prevalence: 0.5%
* Slightly more common in women
* Onset usually before age 30
* No ethnic differences seen
57
**Bipolar II disorder**
* Etiology
* Course and prognosis
* Treatment
* Etiology same as bipolar I disorder
* Tends to be chronic, requiring long-term treatment
* Treatment same as bipolar I disorder
58
What is the DSM-IV criteria for Dysthymic Disorder?
* Depressed mood for the majority of time of most days for at least 2 years (children for at least 1 yr)
* At least 2 of the following:
* Poor concentration or difficulty making decisions
* Feelings of hopelessness
* Poor appetite or overeating
* Insomnia or hypersomnia
* Low energy or fatigue
* Low self-esteem
* During the 2-year period
* The person has not been without the above symptoms for \>2 months at a time
* No major depressive episode
59
For Dysthymic Disorder, the patient must never have had.....
a manic of hypomanic episode
would make diagnosis bipolar or cyclothymic disorder
60
What is Double Depression?
Patients w/ major depressive disorder with dysthymic disorder during residual periods
61
What is the acronym for Dysthymic Disorder?
**CHASES**
* poor **C**oncentration or difficulty making decisions
* feelings of **H**opelessness
* poor **A**ppetite or overeating
* in**S**omnia or hypersomnia
* low **E**nergy or fatigue
* low **S**elf-esteem
62
**Dysthymic Disorder**
* Lifetime prevalence: \_\_\_%
* Women vs. men
* Onset before age ___ in 50% of patients
* Lifetime prevalence: 6%
* 2-3x more common in women
* Onset before age 25 in 50% of patients
63
What is the course and prognosis of Dysthymic Disorder?
* 20% of patients will develop major depression
* 20% will develop bipolar disorder
* \>25% will have lifelong symptoms
64
How is Dysthymic Disorder treated?
* Cognitive therapy and insight-oriented psychotherapy are the most effective
* Antidepressant medications are useful when used concurrently (SSRIs, TCAs, MAOIs)
65
What is cyclothymic disorder?
Alternating periods of hypomania and periods with mild to moderate depressive symptoms
66
What is the DSM-IV criteria for cyclothymic disorder?
* Numerous periods with hypomanic symptoms and periods with depressive symptoms for at least 2 years
* The person must never have been symptom free for \>2 months during those 2 years
* No hx of major depressive episode or manic episode
67
**Cyclothymic Disorder**
* Lifetime prevalence: \_\_\_%
* May coexist with \_\_\_\_\_\_\_\_\_.
* Onset usually age \_\_\_\_\_.
* Males vs. Females
* Lifetime prevalence: \<1%
* May coexist with **borderline personality disorder**
* Onset usually age 15-25
* Males = Females
68
**Cyclothymic Disorder**
* Course & prognosis
* Treatment
* Chronic course
* 1/3 of patients eventually diagnosed with bipolar disorder
* Antimanic agents used to treat bipolar disorder
69
What are 6 other disorders of mood in DSM-IV?
* Minor depressive disorder
* Episodes of depressive symptoms that do not meet criteria for MDD
* Euthymic periods are also seen, unlike dysthymic disorder
* Recurrent brief depressive disorder
* Premenstrual dysphoric disorder
* Mood disorder due to a general medical condition
* Substance-induced mood disorder
* Mood disorder not otherwise specified (NOS)
