1
Q
Define Mood Episode.
What are the 4 types?
A
Distinct period of time in which some abnormal mood is present:
- Major Depressive Episode
- Manic Episode
- Hypomanic Episode
- Mixed Episode
2
Q
DSM 5 diagnostic criteria for Major depressive episode:
A
5+ of the following present for AT LEAST 2 weeks:
- *At least #1 or #2 must be present (“SIGECAPS”)
1. Depressed mood predominates
2. Anhedonia
3. Appetite/ weight changes
4. Worthlessness/ Guilt
5. Sleep disturbance (insomnia/ hypersomnia)
6. Diminished concentration
7. Psychomotor agitation/ retardation
8. Fatigue/ Decreased energy
9. SI - *Can’t be explained by meds/medical condition
- *Significant distress social/ occupational impairment
3
Q
DSM 5 diagnostic criteria for Manic Episode:
A
3+ of the following (4+ if mood is only irritable) for AT LEAST 1 WEEK:
DIGFAST
- Distractibility
- Inflated self esteem/ grandiosity
- ^ goal directed activity/ psychomotor agitation
- Decreased sleep
- Flight of ideas/ racing thoughts
- ^ Talkativeness/ pressured speech
- ^ indulging w/ consequences (shopping, sex, etc)
* *Can’t be explained by meds/medical condition
* *Significant distress social/ occupational impairment
* *Up to 50% patients have comorbid psychosis
4
Q
DIGFAST for mania:
A
Distractibility Insomnia/ Impulsivity Grandiosity Flight of ideas Activity/ Agitation Speech (pressured) Thoughtlessness
5
Q
SIGECAPS for depression:
A
Sleep disturbance Interest loss Guilt Energy decrease Concentration decrease Appetite changes Psychomotor retardation Suicidal ideation
6
Q
DSM 5 Diagnostic criteria for Hypomanic Episode:
A
Same as manic episode, but only lasts AT LEAST 4 DAYS
- *Does not cause marked functional impairment
- *Does not require hospitalization
- *Does not have psychotic features
7
Q
DSM 5 Diagnostic criteria for Mixed Mood Episode:
What is the most predominant mood state in these patients?
How is the condition treated?
A
- Criteria met for manic or hypomanic episode
- 3+ sx of major depressive episode
- Duration of AT LEAST 1 WEEK
- *Note that irritability is the most predominant mood state in these patients
- *Can treat with AEDs like valproic acid
8
Q
Patients with cerebrovascular disease/ stroke are at significant increase risk to develop which mood episode?
A
DEPRESSIVE
**Associated with poorer outcomes
9
Q
4 Disease states that can cause manic mood episodes:
A
- Metabolic disease (hyperthyroidism)
- Neurological disease (MS, temporal lobe seizures)
- Neoplasms
- HIV infection
10
Q
7 Disease states that can cause depressive mood episodes:
A
- Cerebrovascular disease
- Endocrinopathies (Cushings, DM, Ca, TH, etc)
- Parkinson’s
- Viral illness (mono)
- Carcinoid syndrome
- Cancer (pancreatic, lymphoma especially)
- Collagen/ Vascular disease (SLE, etc)
11
Q
Three substances/ meds you didn’t know could cause depression:
A
- antihypertensives
- diuretics
- sulfonamides
12
Q
Most common disorder leading to suicide?
A
MDD
13
Q
DSM 5 criteria for Major Depressive Disorder:
A
- At lease 1 major depressive episode
2. NO Hx manic or hypomanic episodes
14
Q
How does MDD commonly present?
- Common sx
- Common age of presentation
A
- Vague somatic complaints like fatigue, HA, abdominal pain, muscle tension, etc.
- Peak onset in 20’s; more common in women that men during reproductive age
15
Q
Describe the sleep changes associated with MDD (4):
A
- Multiple wakings
- Initial and terminal insomnia (rarely hypersomnia)
- REM shifted earlier in night (^^^ REM)
- Decrease slow wave sleep
16
Q
4 risk factors for MDD:
A
- High cortisol (hypothalamic-pituitary-adrenal imbalance)
- Abnormal TH axis
- Adverse childhood experiences (especially death of parent before 11 yoa)
- Genetics (first degree relatives 2-4x ^^^ likelihood)
17
Q
Hamilton Depression Rating Scale:
What is it used for?
A
Measure depression severity and track effectiveness of therapies
18
Q
PHQ-9 Depression Scale:
What is it used for?
A
Depression screening tool used in primary care setting
19
Q
Which antidepressant drug class is the most lethal in OD? What are some ADRs associated with this drug class (5)
A
TCAs
- Sedation
- Weight gain
- Orthostatic Hypotension
- Anticholinergic effects
- ^ QTc interval
20
Q
What are the most common ADRs associated with SSRIs?
3
A
- GI
- Sexual
- Rebound anxiety
21
Q
When are MAOi’s indicated for use?
What are the 2 most important/ dangerous ADR?
What is the most COMMON ADR?
A
- Refractory depression
1. Hypertensive crisis with sympathomimetics or tyramine rich foods
2. Serotonin syndrome when taken in combo with SSRI - # 1 ADR = orthostatic hypotension
22
Q
What are the clinical features of serotonin syndrome? (4)
A
- ANS instability
- Hyperthermia
- Hyperreflexia
- Seizures
23
Q
When are atypical antipsychotics used to treat depression? (2)
A
- Adjunct to SSRI to treat MDD w psychotic features (1st line combo)
- Resistant/ refractory MDD without psychotic features
24
Q
What are 3 possible adjunctive treatments used in tandem with antidepressants to treat refractory MDD?
A
- Triiodothyronine (T3)
- Levothyroxine (T4)
- Lithium
25
What are three indications for ETC?
- Refractory MDD
- Patients cant tolerate meds (preggos)
- Rapid reduction in sx is necessary (immediate suicide risk)
26
Describe the clinical presentation of a MDD with melancholic features (6)
- Anhedonia
- Early morning wakings
- Depression WORSE IN MORNING
- Psychomotor disturbance
- Guilt
- Anorexia
**Same for BP with melancholic features
27
Describe MDD with Atypical Features (5):
- Hypersomnia
- Hyperphagia
- Reactive mood
- Leaden paralysis
- Hypersensitivity to interpersonal rejection
**Same as BP with Atypical features
28
Describe MDD with Mixed Features:
- Manic/ hypomanic sx present during most days of MDE
(^ mood, grandiosity, ^ E/ goal directed bx, etc...)
**Same as BP with mixed features
29
Describe MDD with Catatonia:
| **This type of MDD is especially responsive to what kind of therapy?
- Cataplexy (immobility)
- Purposeless mobility/ Bizarre posturing
- Mutism or echolalia
* *Great response to ECT
30
Describe MDD with Psychotic Features:
Characterized by delusions or hallucinations
**Up to 24-53% of hospitalized geri's with MDD have this
**Same as BP with psychotic features
31
Describe MDD with Anxious Distress (5):
- Keyed up/ Tense
- Restless
- Difficulty concentrating
- Fear bad thing happening
- Loss of control
**Same as BP with anxious/ distress features
32
Peripartum onset MDD:
| - When does it occur?
During pregnancy or within 4 weeks of delivery
**Same as peripartum BP
33
Describe MDD with a Seasonal Pattern:
| What is the specific term used to describe fall/ winter onset? To what type of therapy do these patients respond well?
Temporal relationship between MDD onset and time of year
SAD--Patients get this in fall/ winter and respond to light therapy
**Same as BP with seasonal pattern
34
How long does normal bereavement last?
| What should NOT be present in this normal, self limiting condition (3)?
- May last months
- NO psychosis
- NO disorganization
- NO SI
35
DSM 5 Diagnostic criteria for Bipolar I Disorder:
- What are two common features of this disease that are NOT required for dx?
- Describe the genetic link?
Occurrence of ONE MANIC EPISODE:
- May have euthimia, MDD, or hypomania between manic episodes, but this is NOT REQUIRED FOR Dx.
- May possibly have psychotic features
**Has highest genetic link of all major psychiatric disorders
36
Best treatment for a preggo having a manic episode?
ECT
37
Which long term therapy for mania decreased Suicide risk?
Lithium
38
What are the ADRs of lithium (10)?
* **Low therapeutic index:
- Weight gain
- Tremor
- GI upset
- Fatigue
- Cardiac arrhythmia
- Seizures/ Coma
- Hypothyroidism +/- goiter
- Polyuria, Polydipsia --> Nephrogenic DI
- Alopecia
- Metallic Taste
39
Define rapid cycling:
4+ mood episodes within one year (MDD, hypomania, or mania)
40
What is the best treatment for Rapid cycling BP or BP with mixed features?
AEDs like valproic acid or carbamazapene act as mood stabilizers
41
How are atypical antipsychotics used to treat BP disorder?
In tandem with mood stabilizer, they give greater and faster improvement
42
DSM 5 criteria for Bipolar II Disorder (2):
| **How do we treat the disease?
1. 1+ Major depressive episode
2. 1+ Hypomanic episode (note: hx of full manic episode will give you BP I)
**Tx is the same as BP I
43
CHASES for Persistent Depressive Disorder:
```
Concentration (poor)
Hopelessness
Appetite changes
Sleep (insomnia/ hypersomnia)
Energy decrease/ fatigue
Self-Esteem (poor)
```
44
DSM 5 Criteria for Persistent Depressive Disorder (3):
| Is the condition more common in men or women?
1. Depressed mood most of the time for 2+ YEARS
(ONLY 1 YEAR for KIDDOS or TEENS)
2. 2+ of "CHASES"
3. Patient is NEVER asx. for more than 2 mos at a time
**More common in women
45
DSM 5 Criteria for Cyclothymic Disorder:
- This condition commonly coexists with ____?
- 1/3 patients with this condition develop___?
1. Numerous periods with hypomanic sx over course of 2 years **NEVER FULL BLOWN EPISODE**
2. Patient is NEVER asx. for more than 2 mos at a time
3. No hx. MDE, hypomania, or manic episode
* *Commonly coexists with borderline personality disorder
* *1/3 patients develop BP I or BP II
46
DSM 5 Criteria for Disruptive Mood Dysregulation Disorder (8):
**What is the age of dx?
Chronic, severe, persistent irritability during childhood/ adolescence:
1. Recurrent outbursts disproportional to situation
2. 3+ times per week; not congruent with dvlpmt.
3. 1+ year duration; no longer than 3 mos w/o sx.
4. Sx. in 2 settings (school, home)
5. Sx started before 10 yoa
6. Pt is bw 6-18 yoa
7. No manic or hypomanic episode sx for longer than 1 day
8. Not concurring w MDD or due to substance use
Psychiatry First Aid
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