Mood Disorders

Throwback to when I had to stop a psychotic pregnant lady from trying to k*** herself

mood

A sustained emotional attitude; typically garnered through patient self report

affect

The external display of feelings; relates more to other’s perceptions of the patients emotional state

within 3 months of stressors that are not traumatic or life-threatening, Distress is out of proportion, symptoms cause marked distress and impairment in functioning, distress is related to stressor and not an escalation, reaction isn’t normal bereavement, symptoms must subside within six months

DSM-5 criteria for Adjustment disorder

college or university adjustment, conscription into military service, death, natural disaster, new marriage, pregnancy, anticipated combat/anticipated loss, retirement, terminal illness in self, parent, companion

What are common precipitants for AD

prior stress exposure (stressful early exposure), hx of mood or eating disorder, family unit disruption/relocations

Risk factors for adjustment disorder

drug/alcohol misuse, SI, abnormal behavior, symptoms of major depressive disorder or other psychiatric disorders

Signs and symptoms of adjustment disorder

psychodynamic psychotherapy, general counseling, CBT, DBT, family therapy, antidepressants, hypnotics, anxiolytic

Treatment for adjustment disorder

5+ symptoms in 2 weeks and at least 1 of the symptoms being depressed mood or loss of pleasure; symptoms must cause significant distress/impairment

DSM 5 criteria for Major Depressive Disorder

sleep disturbances, interest decrease in pleasure activities and sex, guilty feelings, energy decreased, concentration decreased, appetite changes, psychomotor function is decreased, SI

Symptoms of Depression SIG E CAPS

more common in twins, unipolar depression in a parent, abnormalities in amine NTs, neuroendrocrine abnormalities in HPA axis

Biological factors for depression

major life events, interpersonal difficulties, distorted thinking, loss of hopefulness

Psychological factors for depression

other psychiatric disorders, sleep disorders, neurological disorders, hypothyroidism, hypoglycemia/hyperglycemia, anemia, SLE, fibromyalgia, RA, lyme disease, anti-hypertensive medication, steroid, benzos, opiates, substance misuse

DDX for major depressive syndrome

general counseling, CBT, DBT, group therapy

treatment plan for mild to moderate depression (1st line)

SSRIs, SNRIs, TCA, MAOI, Mirtazapine, buproprion, SGA, lithium, ketamine (watch patients under 25 for SI)

Medications for depression (2nd line)

transcranial magnetic stimulation (TMS)

What is the 3rd line treatment of major depressive disorder

ECT (electroconvulsive therapy)

What is the 4th line treatment of major depressive disorder

hospitalization (MSTH Time)

What is the treatment of major depressive disorder if there is serious risk of self-harm/suicide/HI/psychotic symptoms

more treatment steps were associated with high rates of relapse and shorter time to relapse; remission was higher in augmentation group; patients with concurrent disorders or chronic depression were less likely to achieve remission

What was found in the STAR*D trial

depressed mood more often than not (self-reported or observed) for at least 2 years (1 year in kids/teens); 2+ of poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness; Has never been without one from each for more than 2 months

DSM 5 criteria for persistent depressive disorder

MDD

DDX for persistent depressive disorder

psychotherapy works best

Treatment plan for persistent depressive disorder

1+ manic/mixed episode lasting 1+ week week and 3+ of inflated self-esteem/grandiosity; decreased need for sleep; pressured speech; racing thoughts/flight of ideas; distractibility; increased activity; excess pleasurable/risky activity, marked impairment no due to a substance or medical condition

DSM 5 criteria for Bipolar I Disorder

distractibility, indiscretion, grandiosity, flight of ideas, activity increase, sleep deficit, talkativeness

What are the primary symptoms of a manic attack?

No history of an actual manic episode - at least 1 hypomanic and 1 depressive lasting between 4 and 7 days

DSM 5 criteria of bipolar II

A period of abnormally elevated, expansive, or irritable mood lasting 4–7 days, with increased energy or goal-directed activity. The episode must cause noticeable changes in behavior but not result in severe impairment or psychosis.

Symptoms of a hypomanic episode (3+)

A two-week period of depressed mood or loss of interest in activities, along with at least 4 other symptoms (e.g., weight changes, sleep disturbances, fatigue, feelings of worthlessness, suicidal thoughts), causing significant functional impairment.

Symptoms of a depressive episode

2 years of fluctuating mood (1 year in children/teens); hypomanic symptoms (but NOT episodes), Dysthymic symptoms (NO depressive episodes); no more than 2 months symptom free

Cyclothymia DSM 5 criteria

manic/hypomanic episodes, depressive episodes

What are the exclusion criteria for cyclothymia?

under 50 y/o, upper socioeconomic class, family hx, females tend to have more serious cases

Risk factors for bipolar II

Mania is characterized by an elevated or irritable mood, reduced sleep, rapid speech, impulsivity, and disorganized thought, display excessive confidence, risky behaviors, and sometimes psychosis. Suicide risk is significantly higher

Signs and symptoms of bipolar II

substance induced mood disorder, mood disorder secondary to a medical condition

DDX for bipolar II

mood stabilizing medications - seizure meds, lithium (gold standard), psychotic meds

Treatment plan for bipolar II

Suicide attempt made in last 24 months, expected to die, act not initiated during delirium/confusion, act not undertaken for political/religious objective

DSM 5 criteria for Suicidal behavior disorder

deliberate self injury that is not expected to lethal, attains positive feeling or relief from negative state of mind, or to achieve some interpersonal end

DSM 5 criteria for Non-suicidal self injury

Suicide

Death caused by self-directed injurious behavior with intent to die as a result of the behavior.

Suicide attempt

is a non-fatal, self-directed, potentially injurious behavior with intent to die as a result of the behavior, might not result in injury

SI (suicidal ideation)

refers to thinking about, considering, or planning suicide.

isolative/impulsive character, recent life stressor, family hx, depression, substance abuse

Risk factors for complete suicide

substance abuse, mood/anxiety/disruptive disorders, eating disorders, impulsivity, aggression, hopelessness, poor emotional, regulation, and impaired social and problem-solving skills, residential instability, loss of a parent, sexual and physical abuse, gender
nonconformity

Risk factors for SI and Suicide attempts

disciplinary crises, teasing, arguments with a parent or romantic partner, or perceived failure, shame, or humiliation

Precipitants for SI in adolescents

Mood swings, making a plan, talking about great shame/guilt, using alcohol and drugs, anxious, agitation, change in eating/sleeping habits, rage, talking about revenge

Red flags for SI

Restrict the means, safety plans, definite arrangement with therapist/counselor and psychiatrist, CBT, DBT, SSRI, SGA

Treatment for SI

hopelessness

What is a predictor of poor treatment response with SI