Block 3 PSYCH Exam -- Mood Disorders (# 6-10)

Start Studying!

Terms

undefined, object

copy deck

% or people who get at least one mood disorder episode: 20% at some point during lifetime
Characteristics of endogenous depression (vs. Reactive): NO recent stressors
Prominent vegetative symptoms
Characteristics of reactive depression (vs. Endogenous): Entails RECENT stressors
FEWER vegetative symptoms
MILDER depression
Number of episodes to constitute Major Depressive Disorder: One or more
Number of weeks to qualify as Major Depressive Episode: 2 week period or longer
A Major Depressive episode must include at least one of these two: Depressed mood
Anhedonia
Number of symptoms from list to qualify as Major Depressive Episode: FIVE or more
Time period to qualify as Adjustment Disorder: Within 3 MONTHS of stressor(s)

NOT beyond 6 MONTHS after stressor(s) removed
"Psychotic" Depression vs. "Neurotic" Depression: Psychotic -- more acute, more severe

Neurotic -- more chronic, more characterologic

Influence distinction between Major Depression (P) and Dysthymic Disorder (N)
Time period for Dysthymic Disorder: At least 2 years (NOTE: 1 yr. in children)

Never been w/o symptoms for more than 2 MONTHS at a time
Number of symptoms from list needed for Dysthymic Disorder: TWO or more
Diseases within category of UNIPOLAR disorders (3): Major Depressive Disorder
Dysthymic Disorder
Depressive Disorder Not Otherwise Specified
Diseases within category of BIPOLAR disorders (3): Bipolar TYPE I
Bipolar TYPE II
Cyclothymic Disorder
Cyclothymic Disorder: At least TWO YEARS of hypomanic AND dysthymic symptoms
Bipolar TYPE I: One or more MANIC OR MIXED episodes
Bipolar TYPE II: One of more Major Depressive Episodes
AT LEAST ONE HYPOmanic episode

NEVER a full-blown manic or mixed episode
Time period for Manic Episode: At least ONE WEEK

OR, any duration IF hospitalization necessary
Characteristics of a Manic Episode: THREE or more:

Grandiosity; Decreased sleep; Racing thoughts
Distractibility; Increased goal-directed activity
Excessive pleasurable, but potentially dangerous, activities
Characteristics of a HYPOmanic episode: Same as manic

BUT, NOT severe enough to cause marked impairment
Does NOT necessitate hospitalization
NO psychotic features
Characteristics of a MIXED episode: Meets criteria for BOTH Major Depressive AND Manic Episode

Every day for at least ONE WEEK

Causes marked impairment, or necessitates hospitalization
MAY entail psychotic features
Catatonia: In catatonic stupor:
A general absence of motor activity
Mutism, negativism, grimacing

In catatonic excitement:
Violent, hyperactive behavior with no visible purpose
Stereotypies, echo-praxia/lalia, verbigeration
Characteristics of ATYPICAL Depression (4): LEADEN paralysis
Heightened rejection sensitivity
Preserved mood reactivity

2-3x more common in women
Treatment for ATYPICAL Depression: May respond best to MAO-Is

BUT, SSRIs are most commonly used
Differences between SAD and Atypical Depression (3): SAD has less rejection sensitivity
SAD is increased in winter
SAD has greater prevalence in higher latitude areas
Treatment for SAD: May respond to Bright Light Therapy
"Double Depression": Major Depressive Episode superimposed on Dysthymic Disorder
More refractive to therapy: Dysthymic Disorder or Major Depression?: Dysthymic Disorder

Often requires higher doses of meds, and several combos
Who is more likely to be "widowed": Women

Over the age of 65, 50% of them are
Only 14% of men at that age
Med usually wrongfully given to those suffering depression after loss: Benzodiazepines

Subtherapeutic doses w/ poor follow-up
Characteristics that distinguish Depression from "normal" grieving (6): Decreased self-attitude or guilt
Hallucinations/Delusions
Severe functional impairment
Autonomous/Pervasive sadness
Persistent sadness after several months
Personal or family history
Risk factors for Depression in context of loss: Age; Past/Family History; Health

NOT:
Years married; Sex; Social support; Religion
"Quality" of relationship; "Sudden" death
"Subsyndromal" Depression in Grief: LESS severe sadness and anxiety

Broken sleep, anhedonia, but WITHOUT:
Retardation; weight loss; awakenings
Difference in presentation of Depression in elderly: More anxiety and somatic complaints
Less guilt or lowered self-attitude
More likely psychotic

May be "subsyndromal"
Typical age of onset of Bipolar Disorder: Early 20s
Bipolar disorder is often misdiagnosed as these: ADHD
Conduct Disorder
This treatment can actually trigger a manic episode: Anti-depressants
Average age of onset of Major Depressive Disorder: Late 20s

50% of cases are > 40 y.o.
Average time between first two Bipolar episodes: 5 years
Characteristics of "Rapidly cycling" Bipolar: 4 or more episodes per year

Poorer prognosis
Kindling model: "Episodes beget episodes"

With more recurrences, episodes come cloer together
Ultimately, become independent of life circumstances
Average number of episodes in Bipolar pts.: 9 episodes

40% of pts. have > 10
Breakdown of long-term outcome of Bipolar disorder: 15% euthymic
45% euthymic, BUT multiple relapses
30% partial remission
10% chronically ill
Average number of episodes in Depressed pts.: 5-6 episodes over 20 years
When does prevalence of Depression amongst females increase: After puberty

Becomes twice that in men
Who has higher prevalence of Bipolar disorder? Men or Women: Both have the SAME prevalence
Effect of marriage as a risk factor for mood disorder in men/women: Married men have LOWER rate
Married women have HIGHER rate
Problems with psychoanalytic view (2): Doesn't explain mania well
Doesn't explain pts. who DO express anger
Introjection: Picking up attitudes through "osmosis"

Most frequent example: picking up parents' attitudes
Transference: Emotions are displaced from one person to another
Feelings towards others usually displaced onto therapist

Used in psychoanalytic therapy
Free association: Verbalization of whatever comes to mind

Used in psychoanalytic therapy
Discouraged in SHORT-TERM as can lead to regression
Goal of psychodynamic therapy: "Corrective" emotional experience
Four most common obstacles from INTERPERSONAL view: Unresolved grief
Interpersonal disputes
Role transitions
Interpersonal deficits
Therapy in which homework may be involved: Cognitive behavioral therapy
Emphasis of cognitive behavioral therapy: Automatic thoughts that accompany depressed mood state
Twin studies for Bipolar and Depression: Monozygotic twins -- 60% concordance
Dizygotic twins -- 12% concordance
Chromosomes potentially involved in Mood disorders: 5
11
17
X
Effects of reserpine: Anti-hypertensive / antipsychotic

Depletes biogenic amines

CAUSES depression in 15% of pts.
Monoamine Hypothesis: Depression is the result of a monoamine deficiency

Research has failed to fully validate this
Problems w/ neuroreceptor hypothesis (4): ECT -- causes upregulation of 5-HT2A receptor
Buproprion -- NO effect on NE or 5-HT systems
Thyroid hormone -- augments beta-adrenergic function

Propranolol -- may even cause depression in some
These 2 illnesses assoc. w/ loss of hippocampal volume: Major Depressive Disorder
Post-Traumatic Stress Disorder
The brain's major excitatory neurotransmitter: Glutamate
Function of cAMP response-element binding protein (CREB): Among other things, activates genes for BDNF

Hippocampal CREB levels increase in response to chronic anti-depressants
Endocrine abnormalities assoc. w/ Major Depression: Dysregulation of:

Hypothalamic-Pituitary-Adrenal Axis
Hypothalamus-Pituitary-Thyroid Axis
Hypothalamic-Growth Hormone Axis
Depression correlates with DECREASED metabolic acitivity here (part of brain): DORSOLATERAL prefrontal cortex
Depression shows increased metabolic activity here (part of brain): VENTRAL prefrontal cortex
Abnormalities of circadian rhythms in Depression: Pts. are PHASE ADVANCED
Decreased REM latency
Shifting REM into first half of night
Increased density of eye movements

Decrease REM latency correlates with severity
Most common stroke locations assoc. w/ Depression (2): Left frontal lobe and left basal ganglia
Most common stroke locations assoc. w/ Mania (2): RIGHT limbic-cortical circuit, or basal ganglia

Note: mania is much more rare in stroke pts.
Stress Diathesis Model: Certain individuals are more susceptible
Combination of temperament and stress lead to dysfunction
Time for clinical effects of mood disorder medications to be seen: 2-3 weeks
Full response generally requires 6-8 weeks
% of pts. who are non-responders to anti-depressant meds: 33%

Note: same % as placebo responders
Side effects of TCA Histamine receptor blockade (4): Sedation
Weight gain

Hypotension
Delirium
Side effects of TCA ACh muscarinic receptor blockade (6): Dry mouth/eyes
Blurred vision

Urinary retention
Constipation

Decreased memory
Resting tachycardia
Side effects of TCA alpha-1 receptor blockade (3): Orthostatic hypotension
Reflex tachycardia

Potentiation of anti-hypertensive effect of Prazosin
Side effects of TCA alpha-2 receptor blockade (1): Blocks effects of clonidine
Side effects of TCA 5-HT2 receptor binding (4): Anxiety
Insomnia
Ejaculatory dysfunction
Hypotension
Side effects of 5-HT3 receptor binding (3): Nausea
Cramps
Diarrhea
Side effects of MAO-Is (9): Insomnia
Anorgasmia
Weight gain

"Cheese reaction"
Serotonin Syndrome

Daytime somnolence
Orthostatic hypotension
Myoclonus
Edema
Avoid combining MAO-Is and... (2): Opiates (esp. MEPERIDINE)
Amphetamines
Uses of MAO-Is (4): Dysthymic Disorder
"Atypical" Depression
SAD

Possibly, Bipolar Depression
Ensam: Transdermal form of selective MAO-B inhibitor

No dietary restrictions at lowest doses
Foods to avoid on MAO-Is (7): Matured or aged cheese
Fermented/dry sausage
Improperly stored meat
Broad bean pods
Banana peels
All tap beers
Soy condiments
Tertiary amine TCAs act more on which receptor: 5-HT
Secondary amine TCAs act more on what receptor?: NE

Ex. Desipramine
TCA w/ least amount of orthostatic hypotension: Nortriptyline
TCAs w/ least anti-cholinergic effect (2): Desipramine
Nortriptyline
Shape of dose response curve for TCAs: Sigmoidal
Only TCA that has a "therapeutic window": Nortriptyline

Has a curvilinear relationship
What do TCAs inhibit?: Uptake of BOTH 5-HT and NE
Troubling side effects of SSRIs (5): INSOMNIA
SEXUAL dysfunction
APATHY

Anxiety
GI distress
Drugs that may help w/ SSRI induced sexual dysfunction (3): Yohimbine
Ciproheptadine
Amantadine
Duloxetine (Cymbalta) key points: Actions on 5-HT and NE more equally balanced across dosage range
Safe in OD

LOW rate of sexual side effects

Of benefit in chronic pain
Buproprion key points: Inhibits NE and DA (weakly)

May be helpful in Bipolar disorder and ADHD
Helps stop smoking

Safe in OD (not cardiotoxic)

Side effects resemble SSRIs:
BUT, MINIMAL sexual side effects

NOTE: Higher risk of SEIZURES
Doses 450-600 mg/day increases risk 10-fold
Trazodone key points: Weak 5-HT uptake inhibitor, Direct 5-HT2 ANTagonist
Also acts to block alpha-1 receptor

Useful in agitated demented patients
Used as HYPNOTIC in combo w/ SSRIs
Safe in OD

Can cause orthostatic hypotenstion, SEDATION, and priapism
Side effects attributed to increased serotonin (4): Nervousness (anxiety)
GI distress
Sexual problems
Apathy
Nefazodone key points: Similar to Trazodone
Modified to DECREASE alpha-1 blockade

Safe in OD
Side effects similar to TCAs, but MUCH LESS
Does NOT interfere with sleep architecture

NOTE: higher rate of liver failure
Drug pulled from market (2004)
Mirtazapine key points: 5-HT2 and 5-HT3 antagonist
Also INCREASES NE and 5-HT release via alpha-2 blockade
Also, significant histaminergic blockade (sedation, weight gain)

Safe in OD
LOWER rate of sexual side effects

Despite sedtaion, does NOT interfere w/ sleep ARCHITECTURE
Characteristic that distinguishes stimulants from other meds: Clinical effect is RAPID
Atomoxetine (Strattera) key points: Used for treatment of ADHD

Selective NE reuptake inibitor

Allows once-daily dosing
One of these two is usually employed during Lithium "lag period": Antipsychotic
Benzodiazepine
Predictors of poor response (40%) to Lithium (3): Mixed states
Rapid Cycling
Substance abuse

NOTE: such cases may respond better to ANTI-CONVULSANTS
Uses of Lithium (5): Effective for 70-80% of patients with BIPOLAR DISORDER
Helps BOTH manic and depressive episodes

Augmenting agent in Depression
Schizoaffective disorder
Schizophrenia
Aggression and Impulse control problems
Dose related side effects of Lithium (6): TREMOR
Weight gain
Diabetes Insipidus

ECG changes reflecting HYPOkalemia
Cognitive problems
Birth defects
Idiosyncratic side effects of Lithium (3): Alopecia
Facial rash
Aggravation of Psoriasis
Characteristics of mild to moderate Li intoxication: 1.5 - 2.0 mEq/L

Worsened TREMOR
Dysarthria
Ataxia
Weakness
GI effects
Characteristics of moderate to severe Li intoxication: 2.0 - 2.5 mEq/L

Delirium --> Stupor --> Coma
N&V
Ataxia w/ fasciculations
Characteristics of severe Li intoxication: > 2.5 mEq/L

SEIZURES
Renal Failure
Death
% of pts. who fail to respond to or can't tolerate Li: 30 - 50%
Use of these may contribute to Li refractoriness (1): Anti-depressants, particularly TCAs
Carbamazepine is more effective than Li for these: Mixed states
Dysphoric manic states
Rapid cycling

NOTE: it is as effective as Li for euphoric states
Uses of carbamazepine: Seizures (simple P, complex P, generalize T-C)
Neuropathic PAIN
Dose-related side effects of carbamazepine (3): CNS effects
GI effects

When used w/ Li or anti-psychotics --> INCREASED neurotoxicity

NOTE: NOT safe in OD -- cardiac toxicity like TCAs (but less)
IDIOSYNCRATIC side-effects of carbamazepine (5): BM -- leukopenia (10%) & aplastic anemia

Skin -- rash (from mild to life threatening (rare))
--- NOTE: watch for mucus membrane involvement ---

Liver -- elevated LFTs, signs of cholestasis

Hyponatremia
Increased metabolism of oral contraceptives
Valproic Acid key points: Same uses as Carbamazepine PLUS MANIA
Useful in both acute mania and maintenance

Similar range of efficacy to carbamazepine

Side effects include sedation, N&V, diarrhea, weight gain, TREMOR

RARELY: Fatal hepatotoxicity, Hemorrhagic pancreatitis, Agranulocytosis
Major RFs for Valproic Acid's deadly side effects (3): Being under age of 2 (no fatalities > 10 y.o.)
Administration w/ other anti-convulsants
Presence of other medical problems
Lamotigrine key points: 1st approved maintenance therapy for BIPOLAR since Li
Delays mood episodes in Bipolar I

Side effects mainly benign
BUT, serious concern is risk of SERIOUS RASH

Should be TITRATED SLOWLY
Effect of VPA on blood level of Lamotigrine: Doubles it
Effect of CBZ on blood level of Lamotigrine: Halves it
Atypical anti-psychotic that has been approved for mania: Olanzapine
Most effective in ACUTE mania

NOTE: anti-psychotics are typically used as augmenting strategy
Most effective current treatment for mood disorder: ECT
Treatment of choice for catatonia: ECT
ECT is NOT very effective for (2): Dysthymia
OCD
Used for muscle relaxation in ECT procedure: Succinylcholine
Conditions of "greater concern" with regards to ECT (4): Increased ICP
Space-occupying lesions
Recent MI or stroke
Large aneurysm
ECTs effects on memory: Anterograde amnesia up to an hour after treatment

Retrograde amnesia going back several days

Persistent memory complaints are very rare
Seemingly paradoxical mechanisms of ECT: Increases sensitivity of DA receptor (despite anti-psychosis)

Decreases GABA synthesis and release (despite anti-convulsant)
Major Depressive children are LESS likely to present w/ (3): Sleep disturbance
Weight loss
Delusions
Major Depressive children are MORE likely to present w/ (#3): Prominent somatic complaints
Irritability
Social withdrawal
Bipolar Disorder in children is more often... (w/ regards to pattern): Continuous (no episodic pattern)
Most common comorbid anxiety disorder in adults: Generalized Anxiety Disorder
Most common comorbid anxiety disorder in children: Separation Anxiety Disorder
Average length of depressive episode in children: 9 months
Therapy type that appears to be most effective in the short term: Cognitive therapy

Note: may not be feasible in many young children
Only AD approved for treating MDD in pediatric pts.: Prozac
Drugs approved for OCD in pediatric pts. (4): Prozac
Zoloft
Luvox
Anafranil

Start Studying!

Deck Info

Number of cards 135