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Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
Affective Disorders
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Affective Disorders

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Overview of Affective Disroders

Overview of Affective Disroders

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  • Dexamethasone suppression test shows failure to suppress cortisol levels
  • Suicide homocide self-care
  • Wine beer cheese liverCatatonic: antidepressant + antipsychoticAtypical: MAOI
  • Fredrich Nietzsche (der WillezurMacht)Edgar Allan Poe (Gothic Poet)Robert Schumann (Composer)Margaret Trudeau (Descendant of William Farquhar of EIC 15 PMC)Jean Claude Van DamVincent Van Gough
  • * Used for rapid cycling and mixed
  • Transcript

    • 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, can’t control
    • 4. Abnormalities Mood Episodes Mood Disorders (distinct time) (pattern of episodes) Major Depressive Major Depressive Manic Bipolar Mixed Dysthymic Hypomanic Cyclothymic
    • 5. Episodes 1 Mood Episodes (distinct time) Major Depressive Manic Mixed Hypomanic
    • 6. Episodes 2• 2+ weeks • Sleep • 1+ weeks • Distractability increase/decrease • Expansile/ irritable/ • Insomnia• Anhednoia and/or • Appetite/weight elevated mood • Greandiosity depressed mood change • 3+ of DIG FAST • Flight of ideas• 4+ of other SAME • Mood depressed symptoms (4+ if CIGS symptoms • Energy decreased • Activity irritable mood) increased• No medical or • Concentration • No medical or decreased • Speech substance abuse substance abuse cause pressured cause • Interest decreased (Anhedonia) • Significant social and • Thoughtless-• Significant social occupational ness • Guilt/ and occupational worthlessness impairment • 75% have impairment • Suicide thoughts • Psychiatric emergency psychotic symptoms Major Manic Depressive
    • 7. Episodes 3• Same as mania except for • 1+ weeks• 4+ days • Meets criteria for major• No psychotic symptoms depressive AND manic• No significant episodes impairment of function• Not an emergencyHypomanic Mixed
    • 8. Disorders 1 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
    • 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 - SubtypesMelancholic Psychotic Catatonic Atypical Anhedonia Immobility Hyperphagia Early morning Delusions Purposeless Hypersomnia awakening motor activity Psychomotor Negativism Reactive mood disturbances Guilt Bizarre posture Laeden paralysis Hallucinations Hypersensitive to Anorexia Echolalia rejection
    • 11. Seasonal Affective Disorder Type of Depression Diagnostic Triad: Irritability, Carbohydrate Drawing, Hypersomnia Only present in winter Due to lack of sunlight Rx: Light therapy
    • 12. MDD - Etiology Biological Genetic Psychosocial 1. Serotonin decreased 50% mono- 1. Loss of parent 2. Abnormal b- zygotic before 11 years adronergic receptor concordance regulation 2. 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 • Homicide Hospitalization • Cant care for self • Anti-depressants • Adjuvant medication Pharmacotherapy • CBT • Family Therapy Psychotherapy • Non-responding Electro-convulsive • Non-tolerating • Rapid recovery required Rx
    • 15. MDD – Anti-depressantPharmacotherapy Anti-depressants all equally effective and need 4-8/52 to workSSRI TCA MAOI(safer. Better tolerated) (Lethal in Overdose) (Refractory Depression) • Sedation • Orthostatic• Headache hypotension • Weight gain• GI disturbance • Orthostatic • Serotonin syndrome* if hypotension + SSRI• Sexual • Hypertensive crisis if + • Anti-cholinergic effects dysfunction sympathetomimetics or • Aggravates long QT• Rebound anxiety tyramine-rich food syndrome
    • 16. MDD – Anti-depressantPharmacotherapy 2 *Serotonin Syndrome  SSRI + MAOI  Diagnostic triad  Autonomic instability  Hyperthermia  Seizures  May result in coma or death
    • 17. MDD – Adjuvant Pharmacotherapy Conversion of non- Stimulants Antipsychotics responders to (methylphenidate) responders• Indications • Psychotic MDD • Liothyronine • Terminally ill • Levothyroxine • Refractory • Lithium symptoms • L-tryptophan• Cause dependence
    • 18. MDD - ECT Safe May be used alone 8 treatments over 2-3/52 Process 1. Atropine 2. General anesthesia 3. Muscle relaxants 4. Induce generalized seizure S/E: Temporary retrograde amnesia for 6/12
    • 19. MDD - DDx Dysthymia Adjustment Disorder Bipolar II in depressed state Parkinson’s Disease Brain Tumor Cocaine Abuse B-Blocker Side Effect Hyperthyroidism Hypothyroidism Syphilis
    • 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 2 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
    • 22. Dysthymic Disorder – DSM Law of 2’s  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 20’s)  Chronic disorder (MDD is episodic)  Never get psychotic symptoms  20%  MDD  Double Depression: MDD+DD in between MDE’s  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 3 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
    • 27. Bipolar Disorder Bipolar I Bipolar II• 1+ manic or mixed • 1+ MDE episode • 1+ hypomanic episode• Interspersed with • Never a manic episode • MDE (most common) • 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 - Etiology Biological 75% mono- Psychosocial Environmental zygotic 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 Therapy Psychotherapy • 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 4 Mood Disorders (pattern of episodes) Major Depressive Bipolar Dysthymic Cyclothymic
    • 36. Cyclothymic Disorder – DSM DSM - IV – TR  Many alternating periods with hypomanic and depressive 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 MDE Substance – Induced2o General Medical Condition • CVD • Sedative-Hypnotics • Endocrinopathies • Psychostimulant • Parkinson’s 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 Medical Condition • Hyperthyroidism • Antidepressants • Temporal Lobe • Levodopa Seizure • Dopamine • MS Agonists • 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

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