Affective Disorders

Affective (mood disorders) are characterised by emotional disturbances resulting in functional impairment.

Causes: The aetiology of affective disorders can be seen using a biopsychosocial model: 

Biological:

5-HT–> Low levels of endogenous 5-HT and Na are thought to decrease mood

Cortisol –> Overactivation of the HPA axis increases both risk and persistence of low  mood

Psychological:

Beck’s triad –> Negative views about the self, the world and the future seen in depression

Attributional style –> Higher incidence in people who blame themselves for life events

Social:

Stress –> Linked to negative life events, adversity and childhood stress.

Depression

This is a mental condition which affects 3% of global population and is higher incidence in females.

– It is characterised by low mood which leads to functional impairment and emotional distress

Other symptoms:

– Less concentration/attention

– Increases guilt and unworthiness

– Changes in appetite with weight change

– Sleep disturbance (early morning waking)

– Suicidal ideation

– Psychomotor activity changes 

Special Cases:

a) Severe Depression –> This can lead to psychotic symptoms e.g. delusions and hallucinations:

– Delusions are typically mood-congruent –> include delusions of guild, poverty, that they are dead

– Hallucinations will also usually be of defamatory voices or the smell of rotting/decomposing flesh

b) Children –> in children, the core symptom can be either low mood or irritable mood

c) Elderly –> Depression can present as similarly to dementia giving issues with memory.

– Unlike dementia however, the memory loss will have a more rapid

– In addition, depression also causes the biological symptoms e.g. weight loss, sleep disturbance

– Patients are typically worried and aware of their memory loss

– Gives global memory loss whereas dementia causes recent memory loss first

N.B In children, it is advised to not to use SSRIs if possible. If you have to 1st choice is Fluoxetine.

Diagnosis – To be diagnosed, patients require 3 core symptoms which last at least 2 weeks

– Mild = 2 core symptoms + 2 or more other symptoms

– Moderate = 2 core symptoms + 4 or more other symptoms

– Severe = 3 core symptoms + 5 or more other symptoms 

Tests – The Patient Health Questionnaire-9 (scored out of 27) is used to grade depression

– It asks patients to report over the last 2 weeks how often they have been experiencing symptoms

– Made of 9 items which is scored from 0-3

– Mild = 5-9                  – Moderate = 10-14       – Moderate/Severe = 15-19        – Severe = >19 

Management:

– Mild –> Guided self-help or Structured group physical activity Programme

– Moderate or Severe –> 1st line is CBT/IPT and SSRI (continue until well for 6 months)

– When starting someone on SSRIs, review them after 2 weeks. If they are young (<30) or at a higher risk of suicide then suggested to review them 1 week

   after, as a side effect is increased suicidal thoughts initially.

– If multiple treatments have failed –> ECT or Deep brain stimulation of subgenual cingulate cortex

– In an emergency, call the community team or Crisis Resolution and Home Treatment Team (CRHTT)

N.B In children, it is advised to not to use SSRIs if possible. If you have to 1st choice is Fluoxetine.

Anxiety Disorders

Anxiety is an unpleasant emotional state involving subjective fear, discomfort and physical symptoms

–  The problem occurs when anxiety caused autonomic hyperarousal and becomes distressing impairing function

– It affects many people and the incidence in women is double that of men

Causes: Idiopathic, Hyperthyroidism, Heart disease, Drugs (salbutamol, SSRIs, caffeine, steroids)

Generalised Anxiety Disorder:

This is characterized by long-lasting worry that is not focused on any one object or situation.

– Symptoms need to be present for at least 6 months (ICD-10)

Symptoms:

– Insomnia, subjective worry, increased vigilance, autonomic hyperactivity

Diagnosis – Generalise Anxiety Disorder Assessment (GAD-7) scored out of 21

– Mild = 6-10         

– Moderate = 11-15      

– Severe = 16-21

Management:

If mild –> Low intensity interventions e.g. individual guided self-help, group therapy

If moderate/severe –> CBT or SSRI (sertraline is first-line SSRI)

– Be careful in young people as the SSRI increases anxiety initially and can lead to suicidal thoughts

– If acutely anxious –> Benzodiazepine (but not for > 4 weeks)

Panic disorder:

This is a disorder which is characterised by short episodes of intense anxiety which occur unpredictably

Symptoms – Brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, and/or difficulty breathing.

– Attacks last a few minutes and patients have “anticipatory fear” of getting attacks

Management – 1st line is CBT or SSRI

– If SSRI not tolerated or no response after 3 months, then offer imipramine or clomipramine

Phobias 

-this is heightened fear of specific stimuli characterised by avoidance

a) Agoraphobia – fear of crowded situation from which escape is difficult

Management – 1st line is CBT or SSRI

b) Simple Phobia – Single isolated phobias (e.g. injection/spiders)

Management – 1st line is graded exposure therapy and response prevention

c) Separation Anxiety Disorder (children) – fear of being apart from a caregiver

d) Social Phobia – Persistent fear of social situations due to fears that they will be embarrassed

Management – 1st line is CBT –> if unresolving add on an SSRI

Bipolar Disorder

This is characterised by recurrent episodes of altered mood and activity involving up/downswings

– Peak age of onset is in early 20s and it is equally seen in males and females.

– 90% of patients have recurrence of manic or depressive episodes

Symptoms – Patients will have episodes of depression interspersed with mania/hypomania

– Depression –> low mood, anhedonia and low energy for >2 weeks

– Mania –> a period of elevated or irritable mood which required 5 criteria:

i) Elevated/irritable mood lasting 7 days or more

ii) Has at least 3 of: less sleep, flight of ideas, lack of inhibition, high energy, grandiosity etc.

iii) Marked impairment of social functioning

iv) No psychotic symptoms in the absence of mood disturbance

v) No organic factor causing the mania (e.g. stimulant drugs)

– Hypomania –> This shares similar features with mania and lasts for 4 days or more

– Key distinguishing element from mania is that here, there are no psychotic symptoms.

Types:

– Bipolar Disorder I = Mania and Depression (most common)

– Bipolar Disorder II = Hypomania and depression

Management – This involves chronic maintenance treatment and treating depressive/manic episodes

– If patient has symptoms of mania, they need an urgent referral to the community mental health team

– For maintenance therapy –> Offer psychological intervention to patients (CBT) and mood stabalising drug

– 1st line is Lithium –> 2nd line is Sodium Valproate, Olanzapine or Quetiapine

– For mania –> First ensure that the patient stops taking any antidepressant, then treat with antipsychotics

– 1st line is antipsychotic: Olanzapine or Haloperidol or Quetiapine or Risperidone

– For depression –> Treat with antipsychotics alone or in combination with SSRI’s

–  1st line is Quetiapine, Olanzapine or Lamotrigine or Quetiapine and Fluoxetine

– Do not just prescribe SSRIs by themselves as they can precipitate mania 

Schizoaffective disorder

This is a mental disorder which is characterised by having abnormal thought processes and unstable mood.

– Diagnosis is made when person has symptoms of schizophrenia and a depression/bipolar but does not meet the diagnostic criteria for either condition individually

– Can either be bipolar type (bipolar + schizophrenia) or depressive type (depression + schizophrenia)

Diagnosis:

– Main criterion is presence of psychotic symptoms for at least two weeks without any mood symptoms

– If only experiences psychosis during mood episode –> this is a mood disorder with psychotic symptoms

– If psychosis without mood symptoms > 2 weeks –> this is either Schizophrenia or Schizoaffective disorder

Management – Antipsychotics + (mood-stabiliser or anti-depressant) + CBT

Obsessive-Compulsive disorder

This disorder is characterised by the presence of obsessions and compulsions which causes distress

– Associated with parental overprotection and Streptococcal infection in children, Tourette’s syndrome

Symptoms – The 2 main symptoms are having obsessions and compulsions leading to distress

Obsession –> an unwelcome, persistent intrusive thought which is recognised as absurd (egodystonic)

– Patients are aware that this is a product of their own mind

e.g. doubts, ruminations, believing they are always dirty

Compulsion –> a repetitive action that a patient performs with reluctance to neutralise an obsession

e.g. hand-washing, checking, arranging objects in a certain way.

Types:

i) Obsessions and compulsions –> most common is hand-washing concerned with contamination

ii) Checking compulsions in response to obsessional thoughts about potential harm

iii) Obsessions without compulsions (most difficult to treat)

Diagnosis:

– Presence of obsessions and compulsions >1 hour a day for >2 weeks

– Must cause emotional distress or interfere with activities of daily living

Management:

– If mild –> 1st line is CBT and exposure and response prevention (ERP)

– If moderate/severe –> Combined treatment with CBT with exposure and response prevention (ERP) and SSRI