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Psychiatry > Mood Disorders > Flashcards

Mood Disorders Flashcards

1
Q

When do most mental disorders start

A

50% start before age 14

Mood disorders and anxiety common

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2
Q

What is anhedonia

A

Loss of enjoyment or pleasure

Seen in depression

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3
Q

What is psychomotor retardation

A

Slowing of thoughts and/or movement

Can be subjective or objective

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4
Q

How is sleep often affected in depression

A

Early morning wakening is very common
Classified as waking at least 2 hours before the expected/normal time
Often struggle to get to sleep

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5
Q

What is a stupor

A

Absence of function such as action or speech

People will often stop eating and looking after themselves

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6
Q

How would appearance and behaviour someone with depression

A 
Reduced facial expression
Brow is classically ‘furrowed’
Reduced eye contact
Limited gesturing
Hard to build rapport
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7
Q

How is speech affected in depression

A 
Reduced rate and volume 
Speech in monotonous 
Lowered in pitch 
Limited content - short answers 
Longer time between end of question and them answering  - speech latency
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8
Q

What is mood

A

A prolonged prevailing state or disposition

As described by the patient - subjective

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9
Q

How does affect present in depression

A

Depressed and low
Reduced range of affect - ow throughout
Limited reactivity
May report emotional paralysis

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10
Q

How is thought affected in depression

A

Form is normal
May be slower than normal
Content is often negative - guilt, failure etc
Delusions of guilt, nihilism, disease can occur
Suicidal thoughts are common

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11
Q

How is perception affected in depression

A

Not common to be disordered - not delusion or hallucination
Just become more self-conscious and may think people are judging them

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12
Q

What type of hallucination can be seen in depression

A

Almost always auditory
Second person and derogatory - ‘you are a bad person’
Negative thoughts take on a voice
Not very common

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13
Q

How is cognition affected by depression

A

Cognition is often slowed
May complain of poor memory - pseudodementia
Often inattentive and lose track of conversation/stories/films

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14
Q

How is insight affected by depression

A

Insight is usually preserved - people are aware of their symptoms
However, some don’t recognise that it is an illness and not their fault (believe it is due to weakness

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15
Q

Which guidelines are used to classify mental disorders

A

ICD-10 - used in the UK

DSM-5 - USA

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16
Q

What are the different categories of mood disorders

A

DSM-5 = major depressive disorder, persistent depressive disorder

ICD-10 = mania, bipolar disorder, depressive disorder and dysthymia

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17
Q

How are depressive disorders further classified

A

Mild
Moderate
Severe

Major depressive disorder from DSM-5 only corresponds to moderate and severe depressive disorder in ICD-10

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18
Q

How do you separate depression from normal low mood

A

Depression will be clearly abnormal for the patient
Must persist - for weeks
Will interfere with normal function to a significant degree
May have significant physical, psychomotor and psychological changes

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19
Q

What are the general criteria for diagnosing depression

A

Depressive episode should last at least 2 weeks

No hypomanic or manic symptoms at any point in the individuals life

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20
Q

What are the core features of depression

A

Depressed mood - to an abnormal degree and present most of the day for at least 2 weeks
Loss of interest or pleasure in activities
Decreased energy
Very egocentric - about them

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21
Q

List some additional symptoms of depression

A 
Loss of confidence or self-esteem 
Unreasonable guilt 
Suicidal thoughts or behaviour 
Struggling to concentrate 
Change in psychomotor activity - either agitated or retardation 
Sleep disturbance 
Change in appetite
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22
Q

How can you assess the severity of depression

A

Rating scales exist - Hamilton scale, MADRS, Becks Depression Inventory
ICD-10 rates it based on number of symptoms

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23
Q

What constitutes a moderate depressive episode in ICD-10

A

Two core symptoms + four others, to give a total of at least six

Doesn’t matter which symptoms

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24
Q

What constitutes a severe depressive episode in ICD-10

A

All 3 core symptoms + 5 others, to give a total of at least eight

Doesn’t matter which symptoms

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25
Q

Which subcategory of depression is seen in the majority of primary care cases

A

Mild depression

Very common and often transient (gets better on its own with support)

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26
Q

What are the symptoms of a somatic syndrome

A 
Loss of interest and pleasure 
Lack of emotional reaction 
Early wakening 
Depression worse in the morning 
Psychomotor retardation or agitation 
Loss of appetite 
Weight loss - 5% of body weight or more 
Loss of libido

Need at least 4 of these

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27
Q

What are the symptoms of atypical depression

A

Mood reactivity - mood lifts in response to positive events
Weight gain or increased appetite
Hypersomnia
Leaden paralysis - heavy arms/legs
Long standing interpersonal rejection - social or occupational impairment

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28
Q

What is Cotard’s syndrome

A

Type of psychotic depression
Common in the elderly
Nihilistic delusions that they are dead or organs have died

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29
Q

What is seen in psychotic depression

A

Paranoid delusions
Often hypochondriacal
Think people are out to get them or that they are dying

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30
Q

How is chronic depression defined in DSM-5

A

Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years

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31
Q

Describe the pattern of depression

A 
Symptoms begin 
Respond to treatment 
Remission - may stay here 
Can relapse 
Go into recovery 
Can recur
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32
Q

What are the treatment phases for depression

A

Acute - up to 12 weeks
Continuation - 4-9 months
Maintenance - over a year

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33
Q

Which sex commits suicide more often

A

Men

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34
Q

Are mood disorders usually recurrent

A

Yes
Usually have recurrent episodes
May be seen as a chronic illness

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35
Q

How is bipolar disorder classified

A

DSM-5 - by course/pattern
- Bipolar 1 and 2

ICD-10 - by episode severity

  • hypomania
  • mania with or without psychotic features
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36
Q

What is bipolar 1 disorder

A

The classic form of bipolar
Has met the criteria for mania and had previous depressive/hypomanic episodes
Highly disabling manic episodes and episodes of major depression

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37
Q

What is bipolar 2 disorder

A

More common form
Only have the hypomanic and depressive episodes
Haven’t met the criteria for mania

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38
Q

What is bipolar 3

A

Pseudo-unipolar

Only have hypomanic episodes after use of anti-depressants

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39
Q

What are the specifiers for bipolar in DSM-5

A

A list of extra symptoms that helps to further classify the disorder
Includes: anxiety, psychotic features, rapid cycling etc

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40
Q

How is bipolar disorder classified in ICD-10

A

A disorder characterized by two or more
episodes in which the patient’s mood and activity levels are significantly disturbed
On some occasions this is mania or hypomania and others depression
Repeated episodes of hypomania or mania only are classified as bipolar.

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41
Q

When is a diagnosis of depression changed to bipolar

A

On the first episode of hypomania or mania on a background of recurrent depression

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42
Q

What is hypomania

A

A mood disturbance that is below mania
Still and elevated mood state
Very subjective distinction and depends on the patients normal

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43
Q

How does a hypomanic episode present

A 
Elevated mood or irritability to an abnormal degree 
Interferes with normal function 
At least 3 of the following symptoms:
Increased activity or physical restlessness 
Increased talkativeness 
Difficulty concentrating 
Decreased need for sleep
Increased sexual energy 
Mild spending sprees 
Irresponsible behaviours
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44
Q

How long does hypomania need to last to be confirmed

A

AT least 4 days

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45
Q

How long does mania need to last to be confirmed

A

At least a week

Unless hospitalised

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46
Q

How does a manic episode present

A

Predominantly elevated mood (expansive or irritable_ which is definitely abnormal for at least a week
Interferes with normal function
Three of the following symptoms:
Increased activity or physical restlessness
Increased talkativeness
Flight of ideas or racing thoughts
Loss of normal social inhibition - leads to inappropriate behaviour
Decreased need for sleep
Inflated self-esteem
Distractibility or constant changes in activity or plans;
Behaviour which is foolhardy or reckless
Marked sexual energy

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47
Q

What is pressure of speech

A

Very fast speech where they are saying loads
Racing thoughts
Often change topics rapidly

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48
Q

What sort of risk taking behaviour is seen in manic episodes

A

Spending sprees
Foolish business ideas - will invest lots in it
Reckless driving
Starting fights
Risky sexual behaviour - one night stands etc

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49
Q

Which type of episode can lead to hospitalisation - hypomania or mania

A

Mania

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50
Q

How might a manic/hypomanic episode affect appearance/behaviour in the MSE

A

Bright clothes
Distractibility
Loss of normal social inhibitions / overfamiliarity

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51
Q

How might a manic/hypomanic episode affect speech in the MSE

A

Increased talkativeness - hard to interrupt

Punning and clanging

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52
Q

How might a manic/hypomanic episode affect thought in the MSE

A

Increased flow (lots of thoughts)
Flight of ideas & loosening of associations
Grandiosity - believe they have a gift or great new idea

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53
Q

What psychotic symptoms can be seen in bipolar disorder

A

Delusions or hallucinations

The commonest examples are grandiose delusions , self- referential, erotic or persecutory content

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54
Q

What is the lifetime prevalence of bipolar disorder

A 
1-4% 
Bipolar 1 (the 'classic' type) only makes up 1/3 of cases
55
Q

When does bipolar disorder usually start

A

Usually late teens or early 20s
Earlier than depression
Recurrent depression in late teens may be more likely to have some form of bipolar rather than depression

56
Q

Is there a familial link in bipolar disorder

A

YES - strong genetic component

Family history often leads to an earlier onset and more severe case

57
Q

If someone over the age of 60 presents for the first time with bipolar symptoms what must you consider

A

An underlying organic cause

Onset of bipolar itself at this age is very rare

58
Q

Which other disorders often occur alongside bipolar

A 
Anxiety disorders 
Alcohol and drug abuse 
Personality disorders 
Eating disorders
Schizoaffective disorder
Schizophrenia
59
Q

Which other disorder does bipolar share a lot of genetic factors with

A

Schizophrenia

60
Q

Is there a single gene that causes bipolar disorder

A

Nope
Multiple genes each with a very small effect
Also lots of complex interaction between genes and environment

61
Q

What are subsyndromal symptoms

A

Symptoms which occur even when mood is stable - euthymic

Often it is concentration issue

62
Q

Which phase are people with bipolar experience most of the time

A

Majority is asymptomatic

Next most common is the depressive episodes

63
Q

Which mood disturbance is most common in bipolar - depression or mania

A

Depression

64
Q

List some predictors of poor outcomes in adolescent mood disorders

A 
Early-onset
Low socioeconomic status
Subsyndromal mood symptoms
Long duration of illness
Rapid mood fluctuation
Mixed presentations
Psychosis
Comorbid disorders
Family psychopathology
65
Q

Describe suicide risk in mood disorders

A

Suicide risk is increased in all mental disorders
- 15% of those with depression will commit suicide
However, bipolar disorder carries a further increased risk

66
Q

What is the function of the appetitive system

A

To mediate seeking and approach behaviours
Includes pleasure
This is the reward system

67
Q

What areas of the brain are involved in the appetitive system

A 
The ascending dopamine system
Mesolimbic and cortical projections 
Amygdala 
Anterior cingulate 
Orbitofrontal cortex
68
Q

What is the function of the aversive system

A

The function is to promote survival in event of threat (fear/ pain

69
Q

What areas of the brain are involved in the aversive system

A 
ascending serotonin systems
NA / CRF / peptide transmitters
Central nucleus of amygdala
Hippocampus 
Ventroanterior and medial 
Hypothalamus
Periaqueductal grey matter
70
Q

Describe the neurobiological basis of depression

A

It is an altered sensitivity/accuracy of the brain systems evaluating rewards and cues that predict reward from the environment

71
Q

Describe the neurobiological basis of anxiety

A

It is an altered sensitivity / accuracy of brain systems evaluating threat and cues predicting threat within the environment

72
Q

List life/ neurobiological factors that can impact mood disorders

A 
Abnormal brain development
Genetic and developmental effects
Endocrine/Metabolic causes 
Adverse life events
Psychological resilience/ or lack of
Cultural aspects
73
Q

Which neurotransmitters may contribute to depression if there is a deficit of them

A 
Serotonin - basis of lots of treatments 
Norepinephrine
Dopamine
GABA 
BDNF
Somatostatin
74
Q

Which neurotransmitters may contribute to depression if there is an excess of them

A

Acetylcholine (toxic)
Substance P
Corticotrophin Releasing Hormone - this is a stress hormone

75
Q

How is serotonin affected in depression and other mood disorders

A

There is a decrease in receptor binding through the cortical and subcortical regions
There is a reduction in reuptake sites
Responses usually carried out by serotonin are blunted

76
Q

How is norepinephrine affected in depression and other mood disorders

A

Decrease neurotransmission leading to anergia, anhedonia and decreased libido

77
Q

How is dopamine affected in depression and other mood disorders

A

Hypofunction of the system may be the underlying mechanism of loss of pleasure/interest in depression

78
Q

How is GABA affected in depression and other mood disorders

A

Principal neurotransmitter mediating neural inhibitionReductions in GABA observed in plasma and CSFGABA receptors upregulated by antidepressants

79
Q

How is the hypothalamic-pituitary axis affected in depression and other mood disorders

A

It is upregulated
There is also a down regulation of negative feedback controls
Corticotrophin-releasing factor is hypersecreted from the hypothalamus and induces the release of ACTH from the pituitary
The ACTH causes cortisol to be released from the adrenal glands which has many effects
Negative feedback is impaired so there is continual activation and an excess of cortisol
Receptors become desensitised and there’s increased activity of pro-inflammatory mediators and a disturbance of neurotransmitter transmission

80
Q

How do adverse childhood events affect the norepinephrine system

A

These events can produce an overactive response that persists into adulthood
This means that in stressful situations these people may deplete their NE which can lead to depression

81
Q

How can you assess if treatment of a mood disorder is working

A

Proper mood monitoring
Scoring systems for mood can be used
Ask patients what their goals are for feeling better and then check if they are achieving this

82
Q

What is the IDS-30

A

Common scale used for assessing mood
30 questions – very detailed
Takes time so some may struggle to complete it
or someone who struggles with reading may find it hard
Good for someone with treatment resistant depression

83
Q

What is the QIDS

A

Common scale used for assessing mood
Shorter version of the IDS-30
Focuses more on the biological symptoms - sleep, appetite, concentration etc

84
Q

What is the Hospital Anxiety and Depression Scale

A

Common scale used for assessing mood
14 item list that the patient rates themselves
Easy and quick to complete

85
Q

What is the MADRS

A

Montgomery-Asberg Rating Scale
Common scale used for assessing mood
More objective test
It is a 10 item list completed by an observer
Good if patient lacks insight or is too unwell to complete it themselves

86
Q

What is the prescribing trend for antidepressants

A

Number being prescribed is increasing

87
Q

Are antidepressants more or less effective than placebo

A

MORE

All antidepressants tested were more effective than placebo

88
Q

What is lithium used for

A

Maintenance treatment in bipolar

It is a mood stabiliser

89
Q

How is treatment length of antidepressants related to relapse rate

A

The longer you take them for the greater the relative reduction in relapse
Treatment effect persists for at least 36 months

90
Q

If an SSRI doesn’t work you must try another class of anti-depressant - true or false

A

FALSE
One SSRI may work even if another hasn’t
Should try 2 drugs from that class before switching

91
Q

What is the most commonly used class of antidepressants

A

SSRIs

92
Q

What are the ‘top 4’ SSRIs

A

Escitalopram - probably the best
Sertraline
Mirtazapine
Venlafaxine - more adverse effects

93
Q

What are the benefits of sertraline

A

Well established SSRI
Good cardiac safety - good for the elderly
Easy dose titration

94
Q

What are the benefits of mirtazapine

A

Promotes sleep and appetite and weight gain

Good if the patient is struggling with this

95
Q

What should you do if antidepressant therapy doesn’t work

A

Check compliance
Check diagnosis – could they be bipolar? Have dementia?
Rule out substance misuse or physical illness
Address any other predisposing, precipitating and prolonging factors
Then either increase dose, swap drug or combine with another

96
Q

How long should you try an antidepressant before deciding it doesn’t work

A

Must try for 4-6 weeks before deciding to change – takes time to work
Also gives side effects time to pass - usually transient

97
Q

When should you review a patient after starting antidepressants

A

After 1-2 weeks
Assess side effects
After 4-6 weeks to check efficacy

98
Q

How long should someone stay on antidepressants for

A

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
If someone has had 3-4 episodes it might be time to take it for life

99
Q

How should you manage a hypomanic/manic phase

A

Maximise antimanic dose if already on maintenance treatment
Antidepressants should be discontinued
Combination therapy may be required
Hospital admission likely to be required if mania

100
Q

Should you prescribe anti-depressants in bipolar

A

Not without an antimanic drug as well

They should be avoided in those with recent manic/hypomanic episodes or a history of rapid cycling

101
Q

Which drugs can be used in acute mania

A

Antipsychotic is first line treatment- olanzapine, quetiapine or risperidone
Other options- lithium, valproate, carbamazepine
Benzodiazepines can be used for acute symptoms control

102
Q

What are the side effects or risks with taking lithium

A

Narrow therapeutic range so must be monitored - regular ECG and U&Es
Can damage the heart, kidney and brain if too high a dose
Can cause hypoparathyroidism - monitor calcium
GI side effects most common – N&V, diarrhoea (usually settles)
Can exacerbate skin conditions – psoriasis
Can cause a tremor

103
Q

What are the signs of lithium toxicity

A

Dizziness
Nausea
Worsening tremor
Should inform patients of these so that they can present early for treatment

104
Q

Which antidepressants can cause cognition issues

A

Tricyclics

105
Q

Which common drugs cannot be used alongside lithium

A

ACEi

NSAIDs

106
Q

How is ECT administered

A

Put under general anaesthetic and give them a muscle relaxant
Pass current through the brain to cause a seizure for around 20 seconds
Monitor with an EEG to time the seizure and tells you when it stops
Usually given 2x per week as an inpatient
can be acute treatment or maintenance

107
Q

What is ECT

A

Electroconvulsive therapy
Used in the treatment of severe depression or bipolar
Induces seizures

108
Q

What are the contraindications to ECT

A 
Recent MI - within 3 months 
Recent cerebrovascular event 
Intracranial mass lesion 
Phaechromocytoma 
Angina, congestive heart failure, severe lung disease and osteoporosis 
Cant be used in pregnancy
109
Q

Is ECT safe

A

Yes
Very tiny risk of mortality from cardiac or pulmonary complications
Risk of not treating is much greater

110
Q

What are the common side effects of ECT

A

Short term memory impairment - recovers
gradually
Impaired cognitive function - hard to differentiate from that caused by the depression itself

111
Q

Is consent needed for ECT

A

Yes and No
Around 2/3 of patients voluntarily consent to treatment
Need consent if they have capacity - even if detained under the MHA
However some are too ill to have capacity so if second opinion doctor agrees, then ECT can go ahead without consent

112
Q

What are the 5 areas of the 5 areas model of CBT

A 
Life situations, practical problems and relationships
Altered thinking - cognitive
Altered feelings 
Altered physical symptoms
Altered behaviour
113
Q

What is overgeneralising as a thinking error

A

When you apply rules or outcomes from an isolated incident to all cases

114
Q

What is dichotomous thinking as a thinking error

A

All or nothing thinking

Very black and white

115
Q

What is selective abstraction as a thinking error

A

When you focus on one negative detail and this colours your entire experience

116
Q

What is personalisation as a thinking error

A

When you relate external events to yourself with little or no cause

117
Q

What is minimisation or magnification as a thinking error

A

Over or underestimate magnitude of undesirable events

118
Q

What is arbitrary evidence as a thinking error

A

Draw a conclusion in context of no evidence or contrary evidence

119
Q

What is emotional reasoning as a thinking error

A

I feel bad/guilty/therefore I am bad/have something to feel guilty about

120
Q

What are predisposing factors of mental illness

A

Factors that put you at higher risk

Genetics, childhood attachments, childhood trauma or illness

121
Q

What are precipitating factors of mental illness

A

Factors which can trigger an episode

Recent trauma/stress, childbirth, big life changes, new medication (tramadol)

122
Q

What are prolonging factors of mental illness

A

Factors that impede recovery

Similar to precipitating, stuck in hospital or detained, drinking

123
Q

What are protective factors of mental illness

A

Factors which help to prevent episodes or promote recovery

Friends, family, job that they enjoy, meaningful activity

124
Q

What is behavioural action therapy

A

Involves meaningful activities and goal setting

The idea is that the more you do with your day the better you feel

125
Q

What is the Cognitive Behavioural Analysis System of Psychotherapy (CBASP)

A

Create a timeline of life events - start with personal history and people who have influenced
You rate how the patient makes you feel which gives them an idea of how others perceive them
Situational analysis together – look at situations that make them stressed/angry etc to develop coping

126
Q

What is acceptance and commitment therapy

A

You teach patients to accept the negative thoughts and feelings
But they learn to step back and observe them but not actually take them ‘seriously’

127
Q

Which physical medical disorders may present with mood disturbance

A

Endocrine - thyroid

Neuro - epilepsy, Huntington’s

128
Q

What are the mainstays of treatment for altered mood

A

Psychological or psychotherapy - e.g. CBT

Physical treatments

  • antidepressant and other medications
  • ECT
  • These can be use separately OR in combination.
129
Q

List drugs commonly used in the treatment of depression

A

Selective Serotonin Reuptake Inhibitors (SSRI’s)
Tricyclic Antidepressants (TCA)
Monoamine reuptake inhibitors (MAOI’s)

130
Q

List drugs commonly used in the treatment of bipolar

A

Mood Stabilisers - lithium, sodium valproate
Atypical Antipsychotics
Antidepressants

131
Q

List drugs commonly used in the treatment of acute mania

A

Antipsychotics (atypical and typical)
Mood stabilizers (eg Lithium , Sodium Valproate , Lamotrigine)
Benzodiazepines
ECT

132
Q

How common are the ‘baby blues’

A

Affect up to 70% of women after birth

133
Q

What are the main differences between baby blues and post-natal depression

A

Baby blues are more common, presents within a few days of delivery and have mild and self-limiting symptoms

PND presents at any time but usually within 6 months, symptoms are more severe, consistent with depression

Psychiatry (14 decks)

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