affective disorders

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Overview of Affective Disroders

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  • 1. Androu Waheeb

2. To be Discussed Affect Abnormalities Episodes Disorders Episodes secondary to Medical Illness Substance-Induced Episodes Other Disorders of Note 3. Affect Affect = mood = internal emotional state Can be triggered by internal and external stimuli Variation: range and control Normal: wide range, can control Abnormal: abnormal range, cant control 4. AbnormalitiesMood EpisodesMood Disorders (distinct time) (pattern of episodes) Major DepressiveMajor DepressiveManic BipolarMixed Dysthymic Hypomanic Cyclothymic 5. Episodes 1 Mood Episodes(distinct time) Major Depressive Manic MixedHypomanic 6. Episodes 2 2+ weeks Sleep 1+ weeks Distractability increase/decrease Expansile/ irritable/ Insomnia Anhednoia and/or Appetite/weightelevated mood Greandiositydepressed mood change 3+ of DIG FAST Flight of ideas 4+ of other SAME Mood depressed symptoms (4+ ifCIGS symptoms Energy decreased Activityirritable mood)increased No medical or Concentration No medical or decreased Speechsubstance abuse substance abuse causepressuredcause Interest decreased (Anhedonia) Significant social and Thoughtless- Significant socialoccupational ness Guilt/and occupational worthlessnessimpairment 75% haveimpairment Suicide thoughts Psychiatric emergencypsychotic symptoms MajorManic Depressive 7. Episodes 3 Same as mania except for 1+ weeks 4+ days Meets criteria for major No psychotic symptomsdepressive AND manic No significant episodesimpairment of function Not an emergencyHypomanicMixed 8. Disorders 1Mood Disorders(pattern of episodes) Major DepressiveBipolarDysthymicCyclothymic 9. MDD - General DSM-IV TR At least one MDE No previous manic or hypomanic episodes Epidemiology 15% (USA) 12% (SE KSA)1 M:F=1:2 Average onset 40 y 10. MDD - SubtypesMelancholicPsychoticCatatonicAtypicalAnhedoniaImmobility Hyperphagia Early morning Delusions Purposeless Hypersomniaawakening motor activity Psychomotor NegativismReactive mood disturbances GuiltBizarre posture Laeden paralysis HallucinationsHypersensitive to Anorexia Echolalia rejection 11. Seasonal Affective Disorder Type of Depression Diagnostic Triad: Irritability, CarbohydrateDrawing, Hypersomnia Only present in winter Due to lack of sunlight Rx: Light therapy 12. MDD - Etiology Biological GeneticPsychosocial 1. Serotonin decreased 50% mono-1. Loss of parent 2. Abnormal b- zygoticbefore 11 years adronergic receptor concordance regulation2. Poor stability of 3. High cortisol (HPA family structure hyperactivity) 3. Poor social 4. Thyroid disorder functioning (TSH response to TRH blunted) 13. MDD - Course Natural history Self-limiting (6-13/12) Disorders increase in frequency temporally 15% commit suicide (USA) 50% receive treatment 75% treated successfully 14. MDD - Treatment Suicide HomicideHospitalization Cant care for self Anti-depressants Adjuvant medication Pharmacotherapy CBT Family TherapyPsychotherapy Non-responding Electro-convulsive Non-tolerating Rapid recovery required Rx 15. MDD Anti-depressantPharmacotherapy Anti-depressantsall equally effective and need 4-8/52 to workSSRITCAMAOI(safer. Better tolerated) (Lethal in Overdose) (Refractory Depression) Sedation Orthostatic Headache hypotension Weight gain GI disturbance Orthostatic Serotonin syndrome* ifhypotension+ SSRI Sexual Hypertensive crisis if + Anti-cholinergic effectsdysfunctionsympathetomimetics or Aggravates long QT Rebound anxietytyramine-rich foodsyndrome 16. MDD Anti-depressantPharmacotherapy 2 *Serotonin Syndrome SSRI + MAOI Diagnostic triad Autonomic instability Hyperthermia Seizures May result in coma or death 17. MDD Adjuvant PharmacotherapyConversion of non-Stimulants Antipsychotics responders to (methylphenidate) responders Indications Psychotic MDDLiothyronine Terminally illLevothyroxine RefractoryLithiumsymptomsL-tryptophan Causedependence 18. MDD - ECT Safe May be used alone 8 treatments over 2-3/52 Process1. Atropine2. General anesthesia3. Muscle relaxants4. Induce generalized seizure S/E: Temporary retrograde amnesia for 6/12 19. MDD - DDx Dysthymia Adjustment DisorderBipolar II in depressed stateParkinsons Disease Brain TumorCocaine Abuse B-Blocker Side Effect Hyperthyroidism HypothyroidismSyphilis 20. CASE 1 65 y o Widow Not taking care of self Put in geriatric home Wakes up early Does no particular activity Stopped going to Bingo meetings Claims there is nothing for her life 21. Disorders 2Mood Disorders(pattern of episodes) Major DepressiveBipolarDysthymicCyclothymic 22. Dysthymic Disorder DSM Law of 2s Depressed mood most of time most of days for 2+ years without MDE Never without symptoms > 2/12 2+ of CHASES symptoms 1. Concentration reduced 2. Hopelessness 3. Appetite reduced or overeating 4. Sleep increased or decreased 5. Energy reduced 6. Self-esteem reduced Never manic or hypomanic episode 23. Dysthymic Disorder General Epidemiology < 1% F:M = 3:1 Onset before 25 Course (Rule of 20s) Chronic disorder (MDD is episodic) Never get psychotic symptoms 20% MDD Double Depression: MDD+DD in between MDEs 20% BPD 20% Lifelong symptoms 24. Dysthymic Disorder Therapy Psychotherapy Cognitive Therapy Insight-Oriented Therapy Concurrent Anti-depressants SSRI + MAOI + TCA 25. Case 2 28 yo Female Sad since adolescnce Does not remember last fun activity Denis suicidal thought Denies hopelessness Denies sleep impairment 26. Disorders 3Mood Disorders(pattern of episodes) Major DepressiveBipolarDysthymicCyclothymic 27. Bipolar Disorder Bipolar I Bipolar II 1+ manic or mixed 1+ MDEepisode 1+ hypomanic episode Interspersed with Never a manic episode MDE (mostcommon) Dysthymia Hypomanic episode Euthymia 28. Bipolar I - General Epidemiology 1% Onset before 30 Course Untreated episode lasts 3/12 Chronic with relapses 7% do not recur Increased frequency of episodes with progression 50% of treated patients improve 29. Bipolar II General Epidemiology 0.5% Women more common Onset before 30 Course Chronic and requires long term treatment 30. Bipolar I & II - EtiologyBiological75% mono-Psychosocial Environmentalzygotic concordance 31. Bipolar I & II - Therapy Lithium (Mood stabilizer) Carbamezipine or Valproic Acid* (Anticonvulsant used as mood stabilizer)Pharmacotherapy Olanzapine (atypical antipsychotic) Supportive Psychotherapy Family TherapyPsychotherapy Group Therapy More treatments than MDD Works well Electro-convulsive Rx 32. Bipolar I & II Therapy 2 Lithium Side Effects (GGD.FAWLT.UC.SAM) 1.GI Disturbances 2. Gotire or Hypothyroidism 3. PolyDipsia 4. Fatigue 5. Arrhythmia 6. Weight Gain 7. Leukocytosis 8. Tremor 9. PolyUria 10. Coma 11. Seizures 12. Allopecia 13. Metallic Taste 33. Bipolar I & II Rapid Cycling 4+ episodes in 1 year Especially responsive to anti-convulsants Carbamezipine Valproic acid 34. CASE 3 35 yo Male Brought by wife Takes out loans to start business 3 hours of sleep Compares himself to Bill Gates Previous suicide attempt Previously felt hopeless 35. Disorders 4Mood Disorders(pattern of episodes) Major DepressiveBipolarDysthymicCyclothymic 36. Cyclothymic Disorder DSM DSM - IV TR Many alternating periods with hypomanic anddepressive symptoms for 2+ years Never symptom free for > 2/12 Never MDE or Manic Episode Epidemiology < 1% Coexist with Borderline Personality Disorder Onset 15-25 37. Cyclothymic Disorder Therapy Course Chronic 33% BPD Anti-manic agents used for BPD 38. CASE 4 28 yo student Female Feels moody Admits episodes of extreme happiness in last 2 years Every day for a period Admits lapse of judgment a/w increased energy Irrational depression of mood 39. Other Causes of MDESubstance Induced2o General MedicalCondition CVD Sedative-Hypnotics Endocrinopathies Psychostimulant Parkinsons Dx withdrawal Mononucleosis Anti-convulsants Carcinoid Syndrome Anti-psychotics Lymphoma Alcohol Pancreatic CA Anti-hypertensives SLE Barbituates Corticosteroids Diuretics 40. Other Causes of Manic Episode Substance Induced2o General MedicalCondition Hyperthyroidism Antidepressants Temporal Lobe Levodopa Seizure Dopamine MSAgonists Neoplasms Sympatomimetics HIV Bronchodilators Corticosteroids 41. Other Disorders of Note Minor Depressive Disorder Not meet criteria for MDD (symptoms) Not meet criteria for DD (euthymic periods) Recurrent Brief Depressive Disorder Premenstrual Dysphoric Disorder Mood Disorder Not Otherwise Specified (NOS) 42. References1. Abdelwahid HA, Al-Shahrani SI. Screening of depression among patients in Family Medicine in Southeastern Saudi Arabia. Saudi medical journal. Sep;32(9):948-52.2. First Aid for the Psychiatry Clerkship