Affective Disorders

Question 1

what are mood disorders?

Answer 1

• disorders of mental status and function where altered mood is the (or a) core feature
• a term referring to states of depression and of elevated mood - mania
• the commonest group of mental disorders
• recognition and management forms a large component of activities for GPs, psychiatrists and clinical psychologists

Question 2

• disordered mood can present as a ______ problem or as a __________ of other disorder or illness, e.g. cancer, dementia, drug misuse or medical treatment (steroids)
• often associated with ______ symptoms and _____ disorders. focus on the depressive disorders

Answer 2

primary

consequence

anxiety

anxiety

(If anxiety and depression then treat depression first as often the treatment of the depressive disorder helps with the anxiety symptoms)

Question 3

what classification systems are avalible?

Answer 3

• ICD-10 - International Classification of Disease 10th Edition – World Health Organisation
• DSM-5 - Diagnostic and Statistical Manual of Mental Disorders 5th Edition – American Psychiatric Association

Question 4

what is depression?

Answer 4

•Symptom - An emotion within the range of normal experience

• describe a state of feeling, or mood, that can range from normal experience to severe, life-threatening illness
• a ‘systemic’ symptom (complaint) with similarities to fatigue and pain
• typically considered as a form of sadness, not just an absence of happiness
• Syndrome - A constellation of symptoms and signs
• Recurrent illness - Recurrent depressive disorder
• A leading cause of disability worldwide
• A common condition

Question 5

When does depression become abnormal?

Answer 5

•no clear and convenient division. consensus problematic, often a matter of perspective

psychiatry places emphasis on:

1. persistence of symptoms
2. pervasiveness of symptoms
3. degree of impairment
4. presence of specific symptoms or signs

Question 6

SYMPTOMS OF DEPRESSIVE ILLNESS occurs in 3 spheres which are what?

Answer 6

PSYCHOLOGICAL

PHYSICAL

SOCIAL

Question 7

what are depressive symptoms that may be present in the psychological sphere?

Answer 7

CHANGE IN MOOD:

DEPRESSION - May find diurnal variation

ANXIETY - inability to relax

PERPLEXITY - particularly in Puerperal illness

ANHEDONIA

CHANGE IN THOUGHT CONTENT:

GUILT, HOPELESSNESS, WORTHLESSNESS

ANY NEUROTIC SYMPOMATOLOGY e.g.. Hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks.

IDEAS OF REFERENCE

DELUSIONS AND HALLUCINATIONS if severe (psychotic symptoms)

Question 8

what are depressive symptoms that may be present in the physical sphere?

Answer 8

CHANGE IN BODILY FUNCTION:

ENERGY - Fatigue

SLEEP

APPETITE - weight loss

LIBIDO

CONSTIPATION

PAIN

CHANGE IN PSYCHOMOTOR FUNCTIONING:

AGITATION (restlass anxiety)

RETARDATION (thoughts, speech and movement slowed)

Question 9

what are depressive symptoms that may be present in the social sphere?

Answer 9

LOSS OF INTERESTS

IRRITABILITY

APATHY

WITHDRAWAL, LOSS OF CONFIDENCE, INDECISIVE

LOSS OF CONCENTRATION, REGISTRATION & MEMORY

Question 10

what is stupor?

Answer 10

a state of extreme retardation in which consciousness is intact. The patient stops moving, speaking, eating and drinking. On recovery can describe clearly events which occurred whilst stuporose

Question 11

Depression – ICD-10

what is their definition of depression?

Answer 11

• Last for at least 2 weeks
• No hypomanic or manic episodes in lifetime
• Not attributable to psychoactive substance use or organic mental disorder (some symptoms of depression may overlap with those)
• If psychotic symptoms or stupor then severe depression with psychotic symptoms - Need to exclude other psychotic illnesses first like schizophrenia

Question 12

Depression – ICD-10 – Somatic Syndrome:

One diagnosis within the depressive disorders is somatic syndrome - what is classed as somatic syndrome?

Answer 12

• Marked loss of interest or pleasure in activities that are normally pleasurable
• lack of emotional reactions to events or activities that normally produce an emotional response
• waking 2 hrs before the normal time
• Depression worse in the morning
• Objective evidence of psychomotor agitation or retardation
• Marked loss of appetite
• Weight loss (5%+ of body weight in a month)
• Marked loss of libido

Question 13

Mild Depression – ICD-10

what is classed as mild depression?

Answer 13

Left is core symptoms - at least 2 of 3

Then a further 2 form the list on the right

Question 14

Moderate Depression – ICD-10

what is classed as moderate depression?

Answer 14

Same 2 lists

But 4 symptoms from the left

Question 15

Severe Depression – ICD-10

what is classed as severe depression?

Answer 15

All 3 of core symptoms

Then at least 5 from right hand list

Question 16

how common is Post-natal Depression?

Answer 16

• increased risk of psychiatric admission in the 30 days following childbirth (risk for 24m)
• 75% of women experience ‘blues’ within 2 weeks (passes quickly)
• 10% of women develop MDD within 3-6 months
• ‘puerperal psychosis’ - 1 in 500 deliveries with a risk of recurrence of 1-3 with subsequent deliveries
• despite intuitive appeal - no association with hormonal changes has ever been demonstrated

Question 17

what are some differential diagnosis you should consider in a depressive disorder?

Answer 17

• Normal reaction to life event
• Seasonal Affective Disorder
• Dysthymia
• Cyclothymia
• Bipolar
• Stroke, tumour, dementia
• Hypothyroidism, Addison’s, Hyperparathyroidism
• Infections – Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
• Drugs

Question 18

what are the main evidence based treatments for depression?

Answer 18

• Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic antidepressants (TCAs), Monamine Oxidase Inhibitors, Other antidepressants
• Psychological Treatments - CBT, IPT, Individual dynamic psychotherapy, family therapy
• Physical Treatments - ECT, Psychosurgery, DBS, VNS

Question 19

how do you measure and diagnose depressive disorders?

Answer 19

• SCID (Structured Clinical Interview for DSM disorders)
• SCAN (Schedules for Clinical Assessment in Neuropsychiatry) (aligns with ICD-10)
• HDRS (Hamilton Depression Rating Scale)
• BDI-II (Beck Depression Inventory II)
• HADS (Hospital Anxiety and Depression Scale)
• PHQ-9 (Patient Health Questionnaire 9)

Question 20

Summary:

• Affective disorders are ________, _______ and ________
• Depression is a leading cause of morbidity _______
• All have effective __________
• Depressive disorders can be classified and symptoms _________

Answer 20

common

recurrent

disabling

globally

treatments

measured

Question 21

what is mania?

Answer 21

• a term to describe a state of feeling, or mood, that can range from near-normal experience to severe, life-threatening illness
• rarely a symptom (unlike depression), often associated with grandiose ideas, disinhibition, loss of judgment; with similarities to the mental effects of stimulant drugs (AMPH, cocaine)
• typically considered as a form of pathological, inappropriate elevated mood

Question 22

how do you classify someone as having mania?

Answer 22

• no clear and convenient division. consensus problematic, often a matter of judgment of deviation from ‘normal self’
• psychiatry places emphasis on: (Same 4 emphasis as depressive disorders)

1. persistence of symptoms
2. pervasiveness of symptoms
3. degree of impairment
4. presence of specific symptoms or signs

Question 23

how does ICD-10 classify hypomania?

Answer 23

• Lesser degree of mania, no psychosis,
• Mild elevation of mood for several days on end
• Increased energy and activity, marked feeling of wellbeing
• Increased sociability, talkativeness, overfamiliarity, increased sexual energy, decreased need for sleep
• May be irritable
• Concentration reduced, new interests, mild overspending
• Not to the extent of severe disruption of work or social rejection

Question 24

how does ICD-10 classify mania (with or without psychosis)?

Answer 24

• 1 Week, severe enough to disrupt ordinary work and social activities more or less completely
• Elevated mood, increased energy, overactivity, pressure of speech (speak rapidly and difficult to follow), decreased need for sleep
• Disinhibition (behaving in a way they wouldn’t normally)
• Grandiosity (elevated sense of yourself)
• Alteration of senses
• Extravagant spending
• Can be irritable rather than elated

Question 25

whata re some differential diagnosis of hypomania and mania?

Answer 25

Psychiatric: - Mixed affective state - Schizoaffective disorder - Schizophrenia - Cyclothymia - ADHD - Drugs and Alcohol Medical: - Stroke, MS, Tumour, epilepsy, AIDS, Neurosyphilis - Endocrine – Cushing’s, hyperthyroidism - SLE

Question 26

whata re some Tools to Measure Symptoms?

Answer 26

SCID SCAN Young Mania Rating Scale (YMRS) - used to measure changes in severity of symptoms, track over time how someone's symptoms are

Question 27

what treatment is avalible for mania?

Answer 27

* Antipsychotics - Olanzapine, Risperidone, Quetiapine * Mood Stabilisers - Sodium Valproate, Lamotrigene, Carbamazepine * Lithium * ECT

Question 28

what are the different types of bipolar disorders?

Answer 28

Different phases, depending on if they are manic or hypomanic, weather they have psychotic symptoms or not, weather they are in a depressive episode with or without psychotic symptoms, can be in remission or not

Question 29

What is ICD-10 definition for the diagnosis of bipolar disorder?

Answer 29

* Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania. * If no mania or hypomania then diagnosis is recurrent depression. * If no depression the diagnosis is hypomania or bipolar disorder * (In DSM-5 a single episode of mania is sufficient to diagnose bipolar disorder.) Very unlikely to have a one of manic episode without the other side

Question 30

what is the epidemiology of bipolar disorder?

Answer 30

* lifetime prevalence rate (n per 100) : 0.7 - 1.6 * point prevalence rate of mania : 0.08 - 0.8 * industrialised nations = non-industrialised * rates for males = rates for females * mean age of onset = 21 (unusual \>30) * some studies - 1/3 onset \< 20 * early onset (15-19) usually with positive FH * no differential prevalence according to income, occupation or educational status * prevalence consistently increased in 1st⁰ relatives (suggesting there is probably a genetic link) * other forms of depression also more common

Question 31

what is the epidemiology of depression?

Answer 31

* lifetime prevalence rate (n per 100): 2.9 - 12 * point prevalence rate of depression: 3.7 - 7.7 * lifetime risk for less severe manifestations - 20 * rates for females exceed rates for males - 2:1 * highest risk from age 18-44 (median 25) * mean age of onset = 27 * onset during old age is not unusual * no overall association with socioeconomic status * MDD less common in those employed * MDD less common in those financially independent (N.B. - direction of effect) * association with lower educational attainment * stable marriage negatively associated with MDD * increased risk in 1st⁰ relatives where proband has MDD (3x) or BPD (2x) * twin studies: MZ ‘v’ DZ = 27% ‘v’ 12% * onset of depression (first episode) associated with excess of adverse life events * ‘exit events’ - separations, losses

Question 32

what is the Clinical Course and Outcome of major depression?

Answer 32

* typical episode lasts 4-6 months * 54% recovered at 26 weeks * 12% fail to recover * 80+% have further episodes (Depression recurrence is actually about 40%) * 15% die by suicide

Question 33

What is the Clinical Course and Outcome of Bipolar Disorder / Mania?

Answer 33

* typical manic episode lasts 1-3 months * 60% recovered at 10 weeks * 5% fail to recover * 90% have further episodes * 1/3 have poor outcome * 1/3-1/4 have good outcome * 10% die by suicide

Question 34

Summary: * Affective disorders can be _______ and symptoms \_\_\_\_\_\_\_\_\_ * Affective disorders are ________ and \_\_\_\_\_\_\_\_ * Mania less common than _______ disorder (which again is less common than depressive disorders) * All have effective \_\_\_\_\_\_\_\_\_

Answer 34

classified measured recurrent disabling bipolar treatments