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92 Cards in this Set

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There are two classifications of mood disorders: unipolar and bipolar. What are the two subclassifications of unipolar?
Major depressive disorder

Dysthymic disorder
What are the four subclassifications of bipolar disorders?
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Bipolar disorder not otherwise specified
What are 4 other classifications of mood disorders?
- Adjustment disorder w/ depressed mood.
- Mood disorder d/t general medical condition
- Substance- induced disorder
- Depressive disorder not otherwise specified
Causes of mood disorders can be biologic, neuroendocrine, genetic, etc. What is the main biologic cause of mood disorders? And 3 examples of it?
Biogenic amine dysregulation.
- Serotonin depletion in depression.
- Low levels 5-HIAA assoc w/ violence and suicide.
- Dopamine activity reduced in depression and increased in mania (become more accepted concept).
What are three neuroendogrine causes of mood disorders?
- Disruption in biogenic amine input to hypothalamus.
- Hyperactivity of HPA axis in depression.
- Immune functions decreased in mania and depression.
Correlation between genetics and mood disorders?
- Bipolar disorders and depressive disorders run in fams.
- Evidence for heredity higher in bipolar
2 other possible causes of mood disorders? (think biology - cell level)
Newer theory: abnormality of mitochondria.

Some believe glutamate causes depression - in mitochondria or elsewhere in cell.
What was the original hope with development of the Dexamethasone Suppression Test?
That it could diagnose depression
What is the Dexamethasone Suppression Test?
Used to differentiate diff types of Cushing's and hypocortisol states. Also used in research of depression.
It is an exogenous steroid given (Dexamethasone) which works on the negative feedback system and suppresses secretion of ACTH.
If pathology exists (ex. hypersecretion), the Dexamethasone won't suppress the secretion of cortisol.
What does the Dexamethasone Suppression test have to do with depression?
Nonsuppression (positive test result) which indicates hypersecretion of cortisol secondary to hyperactivity of HPA axis, is seen in 50% of pts w/ major depression.

This is of limited usefulness b/c of frequent false positives and false negatives.
What are some changes in brain images that might be seen in CT or MRI in mood disorders?
Some pts w/ mania or psychotic depression: enlarged cerebral ventricles on CT.
Some depressed pts: decreased blood flow in basal ganglia.
On MRI: Depressed pts have smaller caudate nuclei and smaller frontal lobes than normal.
- theory: abnormal regulation of membrane phospholipid metabolism.
Define Anhedonia:
Inability to experience feelings of pleasure at all.
What are neuro-vegetative symptoms (aka vegetative symptoms)?
Common somatic manifestations of depression
What are some examples of vegetative signs: PHYSIOLOGIC disturbances assoc w/ mood disturbances? (8)
Anorexia or hyperphagia.
Insomnia or hypersomnia, early am awakening.
Diurnal variation of sx (ex worse in am).
Diminished libido.
Constipation.
Pica.
Abnormal menses.
INSATIABLE hunger and voracious eating (atypical)
Major depression can occur alone or as part of bipolar disorder. What is it referred to when it occurs alone?
Unipolar depression.
2 symptoms that MUST be present to be considered major depression?
Sx present for at LEAST 2 weeks.

CHANGE from previous functioning. Exhibit depressed mood OR loss of interest or pleasure.
Major depression more common in women or men?
Women by 2:1
Especially in married women.

Interesting......yet another reason why I don't want to get married! :)
How often is major depression brought on by a precipitating event?
25%
Other characteristics of major depression?
MAY be worse in morning (diurnal variation).
Psychomotor retardation or agitation.
Usually assoc w/ vegetative signs.
Mood congruent delusions and hallucinations may be present.
Genetics may play a role.
May occur as single episode or recurrent.
What is Pseudodementia?
May LOOK LIKE dementia when there is a significant cognitive dysfunction.

The depression comes before the cognitive impairment and depression can often be a predominating symptom.

Needs to be differentiated from depression.
Take a look at Pocket handbook of clinical psychiatry: DSM IV-TR criteral for MDD: Pg 179.
OR look at notes on slide 17.
This lays out the criteria needed to be present for major depressive disorder.

Too much to type..
Also, look at slide 18 and 20 for some little charts that demonstrate the moods associated with dysthymic disorder and major recurrent depression.
Also take a look at slide 21 b/c i have no idea what that means.
Definition of major depression - recurrent?
2 or more separate major depressive episodes.

Must be at least 2 consecutive months when the full criteria for MDD have not been met.
- if not, it might be a pt in PARTIAL remission for just one depressive episode.
2 main subtypes of major depression?
With PSYCHOTIC features

With MELANCHOLIC features
Definition of major depression w/ psychotic features?
Delusions and/or hallucinations present in addition to symptoms of major depression.
Definition of major depression w/ melancholic features?
Loss of pleasure in all; almost all ativities or lack of reactivity to usually pleasant stimuli.
In major depression with melancholia, the official definition applies to the most severe period. At other times, the patient must have AT LEAST 3 of the following symptoms: (6)
- Depressed mood experienced as qualitatively different from the feeling experienced after a loss.
- Depression worse in the MORNING.
- Awaken at least 2 HOURS before the usual time.
- Marked psychomotor retardation or agitation.
- Significant anorexia or wt loss.
- Excessive or inappropriate guilt.

Can see table 14-5 pt 182 in book for more info.
What are atypical features specifier in major depression?
Can be applied when atypical features predominate during most recent 2 wks of a current major depressive episode in major depressive disorder or in bipolar I or bipolar II disorder when current major depressive episode is most recent mood episode.

Or when these features predominate during the most recent 2 years of dysthymic disorder.
2 characteristics to classify major depression with ATYPICAL FEATURES?
- Mood reactivity (mood brightens in response to actual or potential positive events).

- Requires two of the following:
Hypersomnia.
Leaden paralysis or heavy feeling in arms/ legs.
Long-standing pattern of sensitivity to interpersonal rejection that results in social and occupational dysfunction.
Sig wt GAIN or increase in appetite.
What is major depression with POSTPARTUM ONSET?
Most often in women w/ underlying or preexisting mood/ other disorders.

Sx range from marked insomnia, ability of mood to fatigue to suicide.

Could even observe homicidal and/or delusional beliefs about baby.
What is major depression with a Seasonal Pattern?
- Episodes more common in fall/ winter w/ shortened daylight. Disappears in spring and summer.
- Hypersomnia, hyperphagia, psychomotor slowing.
- Tx: exposure to bright artificial light.
- May see in pts also dxed w/ Bipolar I and II disorders.
What is major depression w/ CATATONIC FEATURES?
Motor immobility (including waxy flexibility or stupor).
Must have at least 2 of:
- Excessive motor activity that's purposeless and not influenced by external stimuli.
- Extreme negativism (rigid posture, resistance to commands).
- Unusual voluntary movements (posturing sterotyped movements, mannerisms, grimacing).
- Echolalia or echopraxia
What is Echolia vs Echopraxia?
Echolia is imitating the SPEECH of another person.

Echopraxia: Imitating the MOVEMENTS of another person.
How is dysthymic disorder different from major depressive disorder?
Difference based on severity, chronicity and persistance.

In dysthymic disorder, depressed mood needs to be present on more days than not for a 2 YEAR PERIOD>
During the 2 years (1 yr for kids/ adolescents), the person has never been w/out sx for more than 2 months.
To be classified as dysthymic disorder, there must be 2 or more of the following while depressed: (6)
- Poor appetite or overeating.
- Insomnia or hypersomnia.
- Low energy or fatigue.
- Low self esteem.
- Poor concentration or difficulty making decisions.
- Feelings of hopelessness.
Onset of dysthymic disorder?
Onset is slow and insidious.

Usually starts early: childhood, adolescence, young adulthood.

Dysthymic disorder increases risk for episode of major depressive disorder.
What id DOUBLE DEPRESSION?
When dysthymic disorder is co-morbid with major depressive disorder.
See slide 33 and 39, 52 and 54
More graphs
Definition of Bipolar I?
At least one MANIC episode is identified with OR WITHOUT major depression.
Incidence of bipolar I?
Lifetime incidence 1%.
Men = women, but more mania in women and more depression seen in men.

Manfestation may follow a seasonal variation.
- Manic occurs more in summer.
- Depressive more in winter and spring.
Diagnostic criteria for mania in bipolar I?
Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization occurs).

During the period of mood disturbance, THREE or more of the criteria of sx have persisted (FOUR if mood is only irritable) and has been present to a significant degree.
What are the criteria of sx of manic episodes? (7)
- Inflated self esteem or grandiosity.
- Decreased need for sleep.
- More talkative than usualy or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility: attn too easily drawn to unimportant or irrelevant external stimuli.
- Increase in goal-directed activity or psychomotor agitation.
- Excessive involvement in pleasurable activities that have high potential for painful problematic consequences (ex. unrestrained spending sprees, sexual indescretions, foolish business investments).
What is exclusion criteria for manic episode?
Manic-like episodes clearly caused by somatic antidepressant tx (meds, ECT light therapy, etc).

These types of mania don't count toward diagnosis of bipolar I disorder.
In the MS exam, what would you see in terms of general appearance and behavior with manic behavior?
Psychomotor agitation

Clothing bizarre or VERY colorful

Intrusive, entertaining, hyperexcited
In the MS exam, what would you see in terms of affect with manic behavior?
Labile,

Intense (may have rapid depressive shifts)
In the MS exam, what would you see in terms of mood with manic behavior?
Euphoric,
Expansive,
Irritable,
Demanding,
Flirtatious
In the MS exam, what would you see in terms of speech with manic behavior?
Pressured,
Loud,
Dramatic,
Exaggerated,
May become euphoric
In the MS exam, what would you see in terms of thought content with manic behavior?
Highly elevated self esteem, grandiose,
Extremely egocentric,
Delusions,
Mood congruent themes of inflated self-worth and power,

Most often grandiose and paranoid, hallucinations less frequent.
In the MS exam, what would you see in terms of thought process with manic behavior?
Flight of ideas (when severe: incoherent).
Racing thoughts.
Neologisms (use of words that have meaning only to the person using them).
Circumstantiality,
Tangentiality
In the MS exam, what would you see in terms of sensorium in manic behavior?
Hightly distractible,
Difficulty concentrating,
Memory intact (if not too distracted),
Abstract thinking intact
In the MS exam, what would you see in terms of insight and judgment in manic behavior?
Extremely impaired,

Often totally denies illness,

Unable to make organized or rational decisions
What is Bipolar II?
At least one HYPOmanic episode AND at least one depressive episode.
Do NOT see Manic episode.

Episode not severe enough to cause AS marked impairment socially or occupationally as bipolar type I

Full criteria on hypomania: table 14-4 pg 182
What is Hypomania?
Elevated mood assoc w/ decreased need for sleep.

Less severe than mania w/ no psychotic features.
What is cyclothymia?
Numerous, closely spaced periods of hypomania sx and numerous periods of depressive sx for at least 2 yrs but No full MAJOR depressive episode.

Dx of depression don't reach threshold for dx of major depressive epidose.
Mood elevation present, but not at the threshold for manic episode.
Onset of Cyclothymia?
Adolescence or early childhood.

Sx often interpreted as temperament prob. Pts may be perceived as moody and unpredictable. Social and occupations probs develop.
Risk of subsequent development of a bipolar disorder.

Table 14-8 pg 186 for full criteria
What are some general medical conditions that can cause mood disorders?
Parkinsons, Huntingtons,
Cerebrovascular condts (infarct),
Endocrine conditions (several),
Autoimmune condts (several),
Infections,
Neoplasms,
Epilepsy,
Head trauma,
Cholesterol lowering agents: very low cholesterol assoc w/ depression
What are some endocrine conditions that can cause mood disorders?
Hyperthyroid,
Hypothyroid,
Hyperparathyroid,
Hypoparathyroid,
Adrenocortical hyperactivity,
Adrenal insufficiency
What are some autoimmune conditions that can cause mood disorders?
SLE,
Vasculitis: antiphospholipid antibody sx
What are some infections that can cause mood disorders?
Neuro-syph,
Hepatitis,
Mono,
HIV
What is a neoplasm that can cause mood disorders?
PANCREATIC CANCER!
What is the Mad Hatter's Syndrome?
Caused by chronic mercury intoxication.

See mania and sometimes depressive sx
What is a substance induced mood disorder?
Persistent and prominent mood disturbance that develops as a direct result and within ONE month of intoxication or withdrawal from a drug of abuse, med or toxin.

The mood disturbance is more severe than that expected w/ uncomplicated intoxication or withdrawal.
Relationship between bipolar disorder and pregnancy?
23% have illness episodes during pregnancy.

52% have illness during postpartum period.
Relationship between unipolar depression and pregnancy?
4.6% - episodes during pregnancy.

30% - episodes during postpartum period.

Bipolar has a lot more incidences w/ pregnancy than unipolar.
What did studies find in regards to episodes of mood disorders in pregnancy and postpartum?
Depression was the SYMPTOM seen most often during pregnancy, but sometimes women manifested a DYSPHORIA (feeling unwell or unhappy) that was due to bipolar disorder.
Risk figures of major affective episodes?
-Episodes of depression were 3.5x more likely during POSTpartum period than during pregnancy.
-RISK of occurrence higher w/ bipolar I, then with bipolar II, then unipolar depression.
-Risk of an illness DURING a FIRST pregnancy greater if woman had bipolar disorder dx BEFORE pregnancy. Not so w/ unipolar depression.
-Postpartum risk was greater if dx preceded a first pregnancy in BOTH bipolar and unipolar disorders.
What is the MC manifestation of an affective episode during and following pregnancy?
Major depression
What are some factors associated with unipolar or bipolar depression DURING PREGNANCY (ranked highest to lowest)?
Having illness onset after 1992 (no one knows why).
Never married.
Unemployed and not a homemaker, student or retiree.
Educated beyond high school.
Having an onset age below median of 33 years.
Having a prior dx of bipolar (I or II).
Relatively few pregnancies (less than 4 vs more than 4).
What are some factors associated with unipolar or bioplar illness in POSTPARTUM PERIOD (ranked highest to lowest)?
Never married.
Educated beyond high school.
Onset age below median of 33 yrs.
Having an episode during any pregnancy.
Unemployed.
Having bipolar dx.
< 4 pregnancies.
Having a more recent onset.
If you undertreat a woman for an affect disorder during pregnancy, what may result? (7)
- Low birth weight of baby.
- Preterm delivery.
- Lower apgar scores.
- Poor prenatal care.
- Failure to recognize or report impending labor.
- Increased risks of fetal abuse.
- Neonaticide or maternal suicide.
3 risks associated with not using antidepressants during pregnancy?
Child that is irritable

Child that has developmental delays

Problematic situations that arise from a disinterested mother
There have been studies over time to determine if SSRIs are safe or not safe to use during pregnancy and there has been conflicting evidence. What is the current recommendation by the FDA?

See slide 72 &73 for specific cases
Healthcare providers should treat depression during pregnancy as clinically appropriate.

Evidence is not sufficient to withhold SSRI treatment from pregnant women or take them off antidepressants if they become pregnant.
What does the American Psychiatric Association and American College of Obstetricians and Gynecologists recommend in terms of pregnancy and depression?
Monitor women for depression and treat appropriately.

Report possible adverse effects to FDA's MedWatch program.
What is mild "baby blues"?
Different from postpartum depression.

Sx: crying, irritability, mild mood swings.
Onset: 1-3-10 days after delivery.
Usually self limiting in 1-2 weeks.
May reflect hormonal changes after delivery, or with stress and sleep deprivation.

If doesn't resolve after 1-2 weeks, consider possible postpartum depression.
What is Postpartum depression?
Meets full criteria for Major Depressive Disorder.

Etiology is related to Major Depressive Disorder.

Must be watchful for several months after delivery as sx can occur later.
Incidence rate of postpartum depression?
Approx 30% women who have had prior depressive episode will experience postpartum depression.

Approx 30% of women w/ postpartum depression report having had a prior depressive episode.

Risk of a 2nd postpartum depression after subsequent pregnancy: 30-50%
What is the effect of postpartum depression on the child?
Evidence indicates that a depressed mother affects child's temperament and cognitive development.
What do some researchers believe about depression that BEGINS for the FIRST time in the postpartum period?
More likely to have a bipolar outcome

Postpartum psychosis is freq a manifestation of bipolar disorder.
What is postpartum psychosis?
May present (in new mother) w/ rapid onset of hallucinations, delusions, mood swings, confusion and insomnia.
Counsel women w/ hx of bipolar disorder and their significant others to report these sx immed if they occur.
Consider risk/benefit of antipsychotics or mood stabilizers during preg and postpartum.
Many req hospitalization.
Need to determine if they have delusions about or thoughts about harming infants.
What are the risk factors for postpartum psychosis? (6)
Sleep deprivation.
Hormonal shifts after birth (rapid drop in estrogen).
Bipolar disorder hx.
Schizoaffective disorder hx.
Past hx or fam hx of postpartum psychosis,
Previous psychiatric hospitalization (esp during prenatal period) for bipolar or psychotic condition.
Difference between postpartum depression vs postpartum psychosis?
May be difficult to differentiate between depression w/ psychotic features and a psychosis related to bipolar illness.

Consider postpartum psychosis in differential when eval for postpartu depression.
-In postpartum psychosis, depressed mood is more often related to rapid mood changes.
-PPP: unusual hallucinations such as olfactory or tactile.
-PPP: hypomanic or mixed mood sx.
-PPP: confusion.
What is a major sx present in both postpartym depression (PPD) and postpartum psychosis (PPP)?
Suicidal thoughts or thoughts of harming infant.

Risk of infanticide.
Difference between psychosis and OCD?
OCD may worsen or be present for first time during perinatal period so must differentiate.

In postpartum OCD:
- experience intrusive thoughts of accidental or purposeful harm to baby.
- not out of touch with reality.
- thoughts are ego-dystonic: their thoughts are more like fears.
What are some interferon and neuropsychiatric symptoms associated with treatment of Hep C? (7)
Fatigue,
Anhedonia/ depression (20-80%),
Insomnia,
Anxiety,
Irritability,
Emotional lability: mania/ hypomania.
Cognitive disturbance.
What is the relationship of depression as a risk factor for Cardiovascular disease?
3-4 fold increase in risk of recurrent cardiac events and death in pts w/ CAD w/ depression.

After controlling for mltpl variables, psychosocial factor index was a stronger risk factor for acute MI than HTN, diabetes, or obesity.

Depression predicts mortality and morbidity in pts who have had CABG procedures.
What is Psychosocial Factor Index?
Combined measurement of:
- depression
- general stress
- life events
- loss of control
What is the relationship of depression in patients with preexisting cardiac disease?
Predictive of FUTURE cardiac mortality and morbidity in pts with CAD.

Applies to those WITHOUT recent cardiac events as well as with recent myocardial infarction.
What was found in a study that looked at MI patients that had depression 1 month after the MI?
They were 7x more likely to have subsequent heart attacks.
What link does NOT exist between MI and depression?
Ppl w/ depression earlier in life.
Depression right before or after heart attack.

Current thought: depression that occurs at this time is biological in origin. Depression serves as a SIGNAL MARKER that something has gone wrong biologically in the body.
What are the proposed mechanisms that link CV disease to depression?
Increased platelet reactivity causing increased platelet aggregation and thrombus formation.

Inflammatory markers are increased in depression and linked to CHF, atherosclerosis, MI, and stroke.
Link between young adults, cardiovascular disease and depression?
Basically, psychosocial stress can be responsible for both depression and CV disease.
Mainly due to increased cortisol levels.

If you have a young adult patient with depression, also suspect alterations in immune system (inflammatory cytokines), defects in platelet clotting, decreased heart rate variability.
Try to reduce stress!
The last 5 slides of this lecture talk about a research study that comes to this conclusion.
Sorry for referring you to the powerpoint so much.
Her slides kinda suck!