Mood disorders (Ch 4)

Question 1

Mood

Answer 1

one’s internal emotional state

external and internal stimuli can trigger moods

Normal to have wide range of moods and to have sense of control over one’s mood

Question 2

Mood episode

Answer 2

distinct periods of time in which some abnormal mood is present.

Depression, mania, hypomania

Question 3

Mood disorders

Answer 3

patterns of mood episodes, includes major depressive disorder (MDD), bipolar I disorder, bipolar II disorder, persistent depressive disorder, and cyclothymic disorder

may have psychotic features (delusions or hallucinations)

Question 4

Major Depressive Episode DSM5 criteria

Answer 4

At least 5 of the following, must have either 1 or 2, for at least 2 week period

1. Depressed mood most of the time
2. Anhedonia (loss of interest in pleasurable activities)
3. Change in appetite or weight (up or down)
4. Feelings of worthlessness or excessive guilt
5. Insomnia or hypersomnie
6. Diminished concentration
7. Psychomotor agitation or retardation (i.e. restlessness or slowness)
8. Fatigue or loss of energy
9. Recurrent thoughts of death or suicide

Question 5

Manic Episode DSM5 criteria

Answer 5

Distinct period of abnormally and persistent elevated, expansive or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week

Includes at least three of the following (four if mood is only irritable):

1. distractibility
2. Inflated self-esteem or grandiosity
3. Increase in goal-directed activity (socially, at work, or sexually) or psychomotor agitation
4. decreased need for sleep
5. Flight of ideas or racing thoughts
6. More talkative than usual or pressured speech (rapid and uninterruptible)
7. Excessive involvement in pleasurable activities that have a high risk of negative consequences (e.g. shopping sprees, sexual indiscretions)

Greater than 50 percent of manic patients have psychotic symptoms

Question 6

Symptoms of Mania

Answer 6

"DIG FAST"
Distractibility
Insomnia/impulsive behavior
Grandiosity
Flight of ideas/racing thoughts
Activity/Agitation
Speech (pressured)
Thoughtlessness

Question 7

Symptoms of major depression

Answer 7

SIG E. CAPS
Sleep 
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor activity
Suicidal ideation

Question 8

Hypomanic episode

Answer 8

distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal directed activity or energy, lasting at least 4 consecutive days, that includes at least 3 symptoms listed for manic episode criteria (four if mood is only irritable)

Question 9

Major Depressive Disorder (MDD) DSM5

Answer 9

At least one major depressive episode
No history of manic or hypomanic episode

Episodes of depressed mood associated with loss of interest in daily activities. May not acknowledge their depressed mood or may express vague, somatic complaints (fatigue, HA, abdominal pain, muscle tension, etc)

Question 10

Sleep problems associated with MDD

Answer 10

Multiple awakenings
Initial and terminal insomnia (hard to fall asleep, early morning awakenings)
Hypersomnia (excessive sleepiness) is less common
Rapid eye movement (REM) sleep shifted earlier in the night and for greater duration with reduced stage 3 and 4 (slow wave) sleep

Question 11

Causes of MDD

Answer 11

decreased CSF levels of 5-HIAA (serotonin metabolite) in depressed patients with impulsive and suicidal behavior

Increased sensitivity to b-adrenergic receptors

High cortisol - hyperactive H-P-A axis, fail to suppress cortisol levels with dexamethasone suppression test

Abnormal thyroid axis

GABA, glutamate, endogenous opiates may have a role

Psychosocial/life events - multiple adverse childhood experience risk factor for later developing MDD

Genetics - first degree relatives 2-4 x more like to have MDD

Question 12

Selective serotonin reuptake inhibitors (SSRIs) side effects

Answer 12

HA, GI disturbance, sexual dysfunction, rebound anxiety

Question 13

SNRI drugs

Answer 13

venlafaxine (Effexor)

Duloxetine (Cymbalta)

Question 14

alpha2-adrenergic receptor antagonist drug

Answer 14

mirtazapine (Remeron)

Question 15

Dopamine-norepinephrine reuptake inhibitor drug

Answer 15

bupropion (Wellbutrin)

Question 16

TCAs

Answer 16

Most lethal in overdose due to cardiac arrhythmias

Side effects: sedation, wt gain, orthostatic hypotension, anticholinergic effects

Can aggravate prolonged QTc syndrome

Question 17

Monoamine oxidase inhibitors (MAOIs)

Answer 17

for 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 with SSRIs

Most common side effect - orthostatic hypotension

Question 18

Adjunct medications used to threat MDD

Answer 18

Atypical antipsychotics with antidepressants for MDD with psychotic features or resistant/refractory MDD w/o psychotic features

T3, levothyroxine (T4), lithium to augment antidepressants in refractory MDD

Methylphenidate in terminally ill

Question 19

Electroconvulsive Therapy (ECT)

Answer 19

For unresponsive or cannot tolerate (pregnant) to pharmacotherapy, need rapid reduction of sxs (immediate suicide risk, refusal to eat/drink, catatonia)

Premedicate with atropine -> general anesthesia (methohexital) -> muscle relaxant (succinylcholine)

Generalized seizure induced, should last 30-60 seconds, no longer than 90 seconds

Need 6-12 tx over 2-3 weeks

Retrograde and anterograde amnesia common - resolve w/in 6 months

Other transient side effects: HA, N, muscle soreness

Question 20

Melancholic features

Answer 20

more likely in severely ill inpatients, including those with psychotic features

Anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, anorexia

Question 21

Atypical features

Answer 21

hypersomnia, hyperphagia, reactive mood, laden paralysis, hypersensitivity to interpersonal rejection

Question 22

Mixed features

Answer 22

Manic/hypomanic symptoms during majority days during MDE

elevated mood, grandiosity, talkativeness/pressured speech, flight of ideas/racing thoughts, increased energy/goal-directed activity, excessive involvement in dangerous activities, and decreased need for sleep

Question 23

Catatonia

Answer 23

catalepsy (immobility), purposeless motor activity, extreme negativism or mutism, bizarre postures, echolalia

Especially responsive to ECT

Question 24

Psychotic features

Answer 24

presence of delusions and/or hallucinations

24-53% of older, hospitalized patients with MDD

Question 25

Anxious distress

Answer 25

feeling keyed up/tense, restless, difficulty concentrating, fears something bad happening, feelings of loss of control

Question 26

Peripartum onset

Answer 26

Onset of MDD during pregnancy or 4 weeks following delivery

Question 27

Seasonal pattern

Answer 27

Temporal relationship between onset of MDD and particular time of year Fall-onset SAD responds to light therapy

Question 28

Bereavement

Answer 28

reaction to a major loss, not a mental illness only lasts for several months Normal bereavement does not include gross psychotic symptoms, disorganization, or active suicidality

Question 29

Bipolar I disorder

Answer 29

episodes of mania and of major depression (not required for dx) - aka manic-depression Between manic episode may be interspersed euthymia, major depressive episodes, or hypomanic episodes Onset before 30, mean age 18 First degree relatives with bipolar are 10x more likely to develop the illness Highest genetic link of all major psych disorders Course chronic with relapses, as disease progresses, episodes more frequent 25-50% will attempt suicide, 10-15% succeed

Question 30

Pharmacotherapy for Bipolar I disorder

Answer 30

Lithium - mood stabilizer, partial reduction of mania. Long term use reduces suicide risk. Acute overdose can be fatal d/t its low therapeutic index Anticonvulsants: carbamazepine and valproic acid - mood stabilizers. useful in rapid cycling bipolar disorder and those with mixed features Atypical antipsychotics - risperidone, olanzapine, quetiapine, ziprasidone - effective as mono/adjunct therapy for acute mania Antidepressants discouraged as mono therapy -> activating mania or hypomania

Question 31

Psychotherapy in Bipolar I disorder

Answer 31

may prolong remission once the acute mania episode has been controlled

Question 32

ECT for Bipolar I disorder

Answer 32

works well in manic episodes, may require up to 20 treatments Effective for refractory or life-threatening acute mania or depression

Question 33

Bipolar II disorder

Answer 33

aka recurrent major depressive episodes with hypomania Hx of one or more major depressive episodes and at least one hypomanic episode Onset usually before 30

Question 34

Rapid cycling

Answer 34

at least four mood episodes (manic, hypomania, depressed) within 12 months

Question 35

Persistent Depressive Disorder (Dysthymia)

Answer 35

Chronic depression most of the time, may have discrete major depressive episodes onset often in childhood, adolescence, and early adulthood Early and insidious onset with a chronic course Treatment with psychotherapy and pharmacotherapy SSRIs, TCAs, MAOIs

Question 36

Persistent Depressive Disorder (Dysthymia) DSM5 criteria

Answer 36

Depressed mood for majority of time most days for at least 2 years (children or adolescents for at least 1 year) ``` At least two of the following: "CHASES" poor CONCENTRATION or difficulty making decisions feelings of HOPELESSNESS poor APPETITE or overeating inSOMNIA or hyperSOMNIA low ENERGY or fatigue low SELF-ESTEEM ``` During 2 year period, and not symptom free for more than 2 months at a time

Question 37

Cyclothymic Disorder

Answer 37

Alternating periods of hypomania and periods of mild-to-moderate depressive symptoms May coexist with borderline personality disorder Onset 15-25 Treat with antigenic agents (mood stabilizers or second gen antipsychotics) as used to treat bipolar disorder

Question 38

Cyclothymic Disorder DSM5 criteria

Answer 38

Numerous periods with hypomanic symptoms (but not full hypomanic episode) and periods of depressive symptoms (but not full MDE) for at least 2 years Never have been symptoms free for more than 2 months during those 2 years No history of major depressive episode, hypomania, or manic episode

Question 39

Premenstrual dysphoric disorder

Answer 39

Mood lability, irritability, dysphoria, and anxiety occur repeatedly during premenstrual phase of the cycle May worsen prior to menopause but cease after menopause SSRIs first line treatment - daily or during luteal phase only OCPs may reduce symptoms GnRH agonists have been used Rare causes need Bilateral oophorectomy with hysterectomy to resolve sxs

Question 40

Premenstrual dysphoric disorder DSM 5 criteria

Answer 40

at least 5 symptoms are present: in the final week before menses, improve within a few days after menses, and are minimal/absent in week postmenses At least one: affective lability, irritability/anger, depressed mood, anxiety/tension At least one (total of at least 5 with above sxs): anhedonia, problems concentrating, anergia, appetite changes/food cravings, hypersomnia/insomnia, feeling overwhelmed/out of control, physical sxs (breast tenderness/swelling, joint/muscle pain, bloating, wt gain) Sx cause clinically significant distress or impairment in functioning

Question 41

Disruptive Mood Dysregulation Disorder (DMDD)

Answer 41

Chronic, severe, persistent irritability occurring in childhood and adolescence Very high rates of comorbidity, especially with ODD, ADHD, mood disorders, and anxiety disorders Psychotherapy - parent management training for patient and family first line Medications for comorbidities Stimulants, SSRIs, mood stabilizers, second gen antipsychotics treat primary sxs of DMDD

Question 42

Disruptive Mood Dysregulation Disorder DSM5 criteria

Answer 42

Severe recurrent verbal and/or physical outburst out of proportion to situation Outbursts 3 or more per week, inconsistent with developmental level Mood between outburst persistently angry/irritable most of the day, nearly every day, and observed by others Sxs for at least 1 year, no more than 3 months without sxs Sxs start before age 10, dx made between 6-18 No episodes meeting full criteria of manic/hypomanic episode longer than 1 day this disorder cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder