S11) Mood Disorders

Question 1

Mood disorders are also known as ‘affective disorders’.

What does this mean?

Answer 1

affect is another term for mood

Question 2

Identify the 2 main mood disorders

Answer 2

– Depression

– Bipolar disorder: type 1 and type 2 (includes episodes of mania, one off depression or chronic depression)

Question 3

In order to diagnose depression, how long should they have the symptoms for?

Answer 3

At least 2 weeks

Question 4

Patients with depressive disorders usually have the symptoms continually for 2 weeks.

Usually need 2 of 3 core symptoms to be diagnosed with depression?

What are the core symptoms of depression?

Answer 4

• Low mood
• Lack of energy
• Lack of enjoyment and interest (anhedonia)

Question 5

Apart from the core symptoms, what are other features of depressive disorders?

Answer 5

• Depressive thoughts (hopelessness, helpless, stuck, no future ahead, guilty thoughts even if they have done nothing wrong, suicidal thoughts)
• Somatic/Biological symptoms (loss of appetite/ weight, lack of sleep - initial insomnia, middle insomnia, late insomnia/ early morning wakening, lack of concentration, pain etc)
• In severe cases, may have psychotic symptoms. (often low mood thoughts, depression can be so severe → can be life threatening)

Question 6

Compare and contrast the difference between a ‘normal’ adjustment reaction and clinical depression in terms of the following:

• Symptom onset
• Energy
• Sleep pattern
• Appetite
• Emotions

Answer 6

Adjustment reaction - e.g. in bereavement: - Adjustment reaction typically occurs after some kind of traumatic event and has fewer somatic features compared to depression. Adjustment reactions do not last as long as depression and tend to have a fluctuating course

– time limited

– symptoms fluctuate (trying to make sense of your loss)

– preoccupation with ‘event’

Depression:

– usually at least 2 weeks

– lack of interest

Question 7

Look at the following example of a person with severe depression.

Answer 7

Question 8

What are the features of Mania (seen in bipolar disorders)?

Answer 8

– Elated Mood

– Increased energy

– Pressure of speech

– Decreased need for sleep

– Flight of ideas (lots of ideas in their mind/ racing thoughts)

– Normal social inhibitions are lost (ppl can become promiscuous, have lots of rs they wouldn’t have with ppl, might go to the shops naked)

– Attention cannot be sustained

– Self esteem is inflated, often grandiose

– May have psychotic symptoms (very positive thoughts about themselves, pts who believe they have special powers)

Question 9

Look at the following example of mania.

Answer 9

Question 10

What is hypomania?

Answer 10

Hypomania refers to symptoms that are still clearly manic but don’t necessarily reach full diagnostic criteria for mania

Question 11

What is bipolar affective disorder?

Answer 11

Diagnosis is made following 2 episodes of a mood disorder at least one of which is mania or hypomania.

Therefore you don’t ever have to have a diagnosis of depression to be given the diagnosis bipolar disorder.

Essentially, bipolar disorder is fluctuations in mood.

Question 12

What is the difference between Bipolar 1 and Bipolar 2?

Answer 12

– Bipolar 1 – discrete episodes of mania only or mania and depression

– Bipolar 2 – discrete episodes of hypomania only or hypomania and depression.

Question 13

How do the polarity of symptoms of Bipolar disorder vary?

Answer 13

Question 14

It is really important in psychiatry that you exclude physical causes of psychiatric symptoms.

There are many illnesses that can cause depressive symptoms.

Provide five examples (differentials)

Answer 14

• Hormone disturbance e.g. thyroid dysfunction- hypothyroidism
• Vitamin deficiencies e.g. vitamin B₁₂ deficiency
• Heart and lung diseases
• Blood vessels malfunction
• Kidney disease
• Chronic disease e.g. renal, CVS & liver failure
• Anaemias
• Substance misuse e.g. alcohol, cannabis & stimulants
• Hypoactive delirium

Question 15

It is really important in psychiatry that you exclude physical causes of psychiatric symptoms.

There are many illnesses that can cause mania like symptoms.

Provide five examples (differentials)

Answer 15

• Iatrogenic e.g. steroid induced
• Hyperthyroidism
• Delirium (hyperactive type)
• Infection e.g. encephalitis, HIV, syphyllis
• Head injury
• Intoxication e.g. stimulants

Question 16

Identify three brain structures involved in depressive symptoms

Answer 16

• Limbic system
• Frontal lobe
• Basal ganglia

Question 17

Describe the limbic system (autonomic effects).

Answer 17

→ Important functions in emotion, memory and motivation

→ Composed of many brain regions, however the main emotion circuit is known as the Papez circuit

Question 18

Describe the structure of the Papez circuit.

Answer 18

Various cortical areas send input to the:

– Hippocampus, which projects to the

– Mammillary bodies

– Via the fornix (white matter, output pathway of the hippocampus)

– The mamillary bodies project to the thalamus and hypothalamus

– The thalamus projects back to the cortex

– The hypothalamus projects down to the pituitary and autonomics mediating some of the somatic effects

– The amygdala is another part of the limbic system, but can be grouped with hippocampus in terms if its connections

Question 19

Describe the role of the Papez circuit.

Answer 19

– No one really knows how this circuit works, however the output from the hypothalamus is likely to be very important

– This circuit is also responsible for memory consolidation, where the hippocampus is able to induce long term potentiation in the cortex to lay down long term memory.

– We see changes in the size and activity levels of these structures in depression and bipolar disorder

Question 20

What is the main hypothesis about how mood is determined?

Answer 20

Determined by functional circuits between these brain areas (Limbic system, Frontal lobe, Basal ganglia)

E.g. the frontal lobe projects to parts of the limbic system which in turn connects to the basal ganglia and the brainstem.

This affects:
– Cognitive processed (thoughts)

– Sympathetic output

– Parasympathetic output

– Motor systems

Question 21

Identify some structures in the limbic system

Answer 21

Question 22

What are the main functions of the limbic system?

Answer 22

• Emotion
• Motivation
• Memory

Question 23

What are the possible limbic system changes in mood disorders?

Answer 23

Question 24

The frontal lobe forms ⅔ of the total cortex- biggest brain lobe.

Identify some functions of the frontal lobe

Answer 24

• Motor function
• Language (Broca’s area)
• Attention
• Memory
• Mood → The inferior portions of the anterior part of the frontal lobe are involved in the
  generation and expression of emotions,
  probably via connections with the amygdala
• Social and moral reasoning
• Executive functions (purposeful goal directed behaviour)

Question 25

What are the 2 different prefrontal cortex regions and their function?

Answer 25

The **ventromedial prefrontal cortex** – is thought to be involved in the **generation of emotions.** While the **orbital prefrontal cortex** is thought to be involved in **emotional responses** – possibly via connection with the amygdala.

Question 26

What are the possible frontal lobe changes seen in mood disorders?

Answer 26

Question 27

Identify the general function of basal ganglia functions.

Answer 27

– Motor function; malfunction of the basal ganglia are implicated in neurological illnesses such as: * Parkinson's disease * Wilson’s disease * Huntington's disease – Psychological function: * Emotion * Cognition * Behaviour

Question 28

Identify some psychological functions of the basal ganglia

Answer 28

- Emotion - Cognition/ thought - Behaviour Changes in basal ganglia volume and activity seen in mood disorders

Question 29

What are the possible basal ganglia changes in mood disorders?

Answer 29

Question 30

For depression and mania, describe the several circuits that could account for symptoms.

Answer 30

– **Prefrontal cortex**: Slowing of thought, executive dysfunction. Altered emotional processing. – **Amgydala**: Abnormal emotional processing – **Basal ganglia:** Impaired incentive behaviour. Psychomotor changes.

Question 31

What are the two main neurotransmitters for depressive disorders?

Answer 31

- Noradrenaline (aka norepinephrine) - Serotonin

Question 32

Describe the similarity of the neurotransmitters (Serotonin and NA) in mood disorders.

Answer 32

Both are **monoamines**. **Monoamine hypothesis** suggests that depressive disorder is due to abnormality in the availability of these neurotransmitters. Less evidence re. role of neurotransmitters in mania.

Question 33

Identify some other neurotransmitters which are important in psychiatric conditions

Answer 33

- Dopamine - Acetylcholine - GABA - Glutamate

Question 34

What are the functions of noradrenaline in the brain?

Answer 34

- Mood - Possible role in behaviour (arousal and attention) – fight or flight response - Implicated in memory functions

Question 35

Describe the synthesis and transport of noradrenaline

Answer 35

Noradrenaline is made in the **locus coeruleus** in the brainstem and transported to several areas of the **cortex**

Question 36

Describe the relation of NA and depression.

Answer 36

**NA thought to be decreased in depression**: – Antidepressants (e.g. SNRI’s, NARI’s and some TCA’s) that increase NA successfully treat depression. (drugs that increase levels of NA treat depression) – Patients who have recovered from depression who show decreased NA levels, have significantly higher rates of relapse. – Postmortem studies of depressed patients vs controls (post-mortem studies suggest lower levels of noradrenaline in the brains of those with depression) Note: SNRI - serotonin noradrenaline reuptake inhibitor NARI - noradrenaline reuptake inhibitor TCA - tricyclic antidepressant

Question 37

What is the role of serotonin in the brain?

Answer 37

- Sleep - Impulse control (link with suicide) - Appetite - Mood

Question 38

Describe the synthesis and transport of serotonin

Answer 38

Serotonin is produced in the **brain stem** (Raphe nuclei) and transported to **cortical areas** and **limbic system**

Question 39

Which three factors cause people to become clinically depressed?

Answer 39

- Predisposing factors - Precipitating factors - Perpetuating factors

Question 40

How is serotonin involved in depression?

Answer 40

**Serotonin is thought to be low in depression**. Evidence to support this: – SSRI’s, SNRI, TCA’s & MAOi’s all successfully treat depression by increasing levels of serotonin in synaptic cleft - drugs that increase serotonin in the brain treat depression. – 5HIAA (metabolite of serotonin) is low in the CSF of patients with depression (particularly those who have attempted suicide). – Tryptophan (precursor for serotonin) depletion causes depression However, not all features of depression are explained by this hypothesis. e.g. despite levels of serotonin rising rapidly following the use of drugs such as selective serotonin reuptake inhibitors, symptoms only improve over the course of weeks to months It might be the case that antidepressants act to change the levels of other neurochemicals, maybe even stimulating neurogenesis in the hippocampus through growth factors such as brain derived neurotrophic factor.

Question 41

What is the treatment of depression? Think of the biological, psychological, social treatments.

Answer 41

Use the biopsychosocial model **Biological** Antidepressants: - First line = Selective Serotonin Reuptake inhibitors. Other options: SNRI’s, TCA’s etc (can give lithium- a strong mood stabilizer + powerful antidepressant - if 2 antidepressants aren't working enough AKA treatment resistant depression) Life threatening/treatment resistant: ECT (electroconvulsive therapy - put pt to sleep, give muscle relaxant, then electric charge passed to the brain to induce a short seizure, do it twice a week for up to 6 weeks → done in life threatening severe depression) **Psychological** – First line treatment for depression: CBT (1 to 1 psychotherapy) **Social** – Help with e.g. isolation, social stressors (including housing, finances), exercise (get hot and sweaty), encourage them to do things they enjoy/ engage in their hobbies

Question 42

What is the treatment of bipolar?

Answer 42

Find treatment that balances out their symptoms depending on their phase.

Question 43

What is the treatment for mania, think biological, psychological and social?

Answer 43

**Biological** – First line: antipsychotics (animaniacs) – Alternatively: mood stabiliser (e.g. lithium, sodium valproate- can't give to women of childbearing age as it is very teratogenic) **Psychological** – Acutely unlikely to be helpful, longer term – psychoeducation (hard to do it) re. BPAD, triggers and signs of relapse. - helpful to educate pts regarding recognising triggers and signs of relapse. **Social** – Treat in a place of safety (mostly in community)– where risk to self (Severely suicidal - then bring them into hospital) and others is minimal. Consideration of implications of mania e.g. debts (excessive spending/ finances).

Question 44

What is the treatment of bipolar depression (bipolar patients between manic episodes)? biological, psychological and social

Answer 44

**Biological** – Can use antidepressant – but ONLY with mood stabiliser cover. (if you just given an antidepressant to someone who is depressed that has bipolar disorder → you will send them high, you must always ask if they have had a manic disorder before, therefore you can't just give an antidepressant) - ECT - Lithium **Psychological** – CBT **Social** – as for unipolar depression e.g. exercise

Question 45

How can we maintain stability in bipolar disorder ( so people that are now well)? biological, psychological, social

Answer 45

**Biological** – Mood stabilisers e.g. lithium, sodium valproate – +/- Antipsychotic (used as a mood stabiliser e.g. Quetiapine) **Psychological** – Psychoeducation re. bipolar affective disorder. – CBT – to help prevent relapses **Social** – Consideration of BPAD on employment e.g. shift work. / consider effects on employment etc. Involvement of family (family support), education of family etc., manage stress as it is a risk factor, keep sleep diaries - as when you become manic, sleep deteriorates over a time period .: it is a good indicator, monitor moods

Question 46

Identify some predisposing factors of depression

Answer 46

- Genetic - Childhood experiences - Female gender

Question 47

Identify some childhood experiences causing depression

Answer 47

**Causation is cumulative:** - Quality of attachment - Quality of parental relationships - Loss of a parent - Bullying

Question 48

In research woman are consistently found to be more likely to suffer from an affective disorder. What are the possible reasons for this?

Answer 48

- Social and **occupational role** (marriage, child care) - Men are more likely to **distract themselves** from depressed mood - Woman are more willing to a**dmit to being depressed**

Question 49

Social stressors are identified as a perpetuating cause for depression. Provide some examples of this

Answer 49

- Social economic status - Unemployment - Financial hardship - Isolation from family and friends

Question 50

Central to the available treatments is that the function of the brain is restored. How can depression be treated?

Answer 50

- **Medication** – direct effect on the biochemistry of the brain - **Social and psychological interventions** *e.g. CBT* – measurable effect on the biochemistry of the brain

Question 51

Illustrate the relationship between the aetiology and treatment of depression

Answer 51