PSC TEST 4

ECT info

-Overuse in the 1940's-mid 1960's -Today mostly for severe depression not responding to medication, severe suicidality -Catatonia i. Brain will shut down ii. Undernotes with adjuration (more scysophenia) -Also could be suicidal constantly find ways and terrible stat of mind and ECT might be quickly -Can't take medications During pregnancy -Modern ECT is like a surgical procedure: anesthesia and muscle relaxants i. past, break teeth and bones oxygen to reduce memory loss heart monitor, EEG monitoring, etc. -Shock levels lower (12-65 volts vs. 150) and briefer (< ½ sec.) -Shocks sometimes applied unilaterally (although this doesn't always work) (12-65 volts vs. 150 and briefer C-onvulsions last several minutes -At least 6-10 treatments in extended periods -High relapse rate (60%)

MOOD DISORDERS Types:

1. (UNIPOLAR ) DEPRESSIVE DISORDERS 2. 1. BIPOLAR DISORDERS

BIPOLAR DISORDERS

1. (Unipolar) Depressive Disorders - Have a depressive and go back feeling normal -inter episode remission - Some people never go to base mode it becomes a normal 2. Bipolar Disorders - Depleted Domaine and neurotransmitter, serotine gone, and then you often depression, physical drain -Some only have mania

DSM-5 Definition of Persistent Depressive Disorder:

1. A chronic pattern of depression that has lasted for at least 2 years. 2. A person experiences depressive symptoms that are mild, moderate, or severe (Major 3. Depression 4. Start early and does not usually merit a severe depression 5. Self-esteem is not good 6. Not really feel like bright 7.Put more effort into Hard to get help for because just there personality and friends won't egnolege

MEDICATIONS FOR MOOD DISORDERS

1. Antidepressants 2. Mood stabilizers 4. New Antipsychotics

With Anxious Distress

1. Anxiety symptoms beyond what would be expected for depressive state. 2. Only anxiety during depression 3. Or only get OCD during depression

TREATMENTS FOR MOOD DISORDERS

1. BIOLOGICAL TREATMENTS FOR MOOD DISORDERS 2. PSYCHOTHERAPY FOR MOOD DISORDERS

TYPES OF BIPOLAR DISORDER

1. Bipolar I 2. Bipolar II 3. Cyclothymia

2. BIPOLAR DISORDERS

1. Bipolar I Disorder 2. Bipolar II Disorder 3. Cyclothymia

ECT side effects

1. Common: Severe headaches; memory loss for events surrounding ECT 2. Less common: Irretrievable loss of long-term memories i. Not much a problem unless you end up forgetting things

i. Cognitive Symptoms (e.g., poor memory & concentration; inability to make decisions)

1. Concentration, memory, comprehension 2. Harder time making decisions 2. Negative mindset doing something good then push it out 2. Extreme negative view of themselves 3. Inadequate, undesirable, inferior, perhaps even evil 5. guild, blame themsleves 6. complain about their intellectual ability poor, confused, remember things, distracted

How DBS works

1. Depression linked to high activity in the subgenual cingulate, a key member of the depression related brain circuit 2. Mayberg drilled two tiny holes into the potions suck and implanted electrodes in the subgenual cingulate a. Electrodes were connected to a battery or pacemaker on the patient's chest or stomach b. Pacemakers powered by electrodes sending low voltage electricity to the brain c. Repeated to recalibrate dperaiion-related brain ciruit

i. Emotional Symptoms (e.g., sadness, crying)

1. Despair 2. Sadness, dejected 3. Miserable, empty and humiliated 4. Loose sense of humor 5. Anxiety, anger, or agitation

a. Different kinds of depressive symptoms can be seen:

1. Emotional Symptoms (e.g., sadness, crying) 2. Cognitive Symptoms (e.g., poor memory & concentration; inability to make decisions) 3. Physical Symptoms (e.g., low energy, decreased appetite, sleep, sex drive, physical pain) 4. Behavior symptoms--> move and speak slowly, less active and productive, spends more time alone

Biological View on Depression:

1. Genetic Factors - Predisposition to unipolar depression - Unipolar 38 percent changes of identical twins to have Sam disorder and 20 percent for fraternal twins 2. Biochemical Factors aka nephron and serotonin 3. Brain Circuits - subgenual cingulate, a subregion of the brain's anterior cingulate cortex, is distinctly part of the depression-related circuit. 4. The Immune system -Depression people display lower lymphocyte actively and higher CRP production and greater body inflammation - Higher migraines, irritable bowel syndrome, choric fatigue syndrome, arthritis

at least 3 of the following 7:

1. Grandiosity or inflated self-esteem 2. Do not need to sleep, 3. Decreased need for sleep 4. Increased talkativeness ("pressure of speech") 5. Flight of ideas or racing thoughts 6. Distractibility 7. Psychomotor agitation or increased in goal-directed activity (e.g. work) 8. Buying sprees, sexual indiscretions, foolish investments, other pleasurable activities. (Poor judgment!)

DSM-5 Diagnosis of Major Depressive Disorder (MDD):

1. MDD entails a history of one or more major depressive episodes 2. Symptoms are severe enough to cause clinically significant distress or impairment

1. (UNIPOLAR ) DEPRESSIVE DISORDERS

1. Major Depressive Episode 2. Persistent Depressive Disorder (similiar former Dysthymia) 3. Premenstrual Dysphoric Disorder (PMDD)

MOOD DISORDERS AND CREATIVITY

1. Mood disorders, (especially bipolar disorder) are over-represented among creative individuals such as poets, writers, and painters 2. About 20% of famous poets found to be bipolar, vs. only about 1% in the general population 3. Many of them committed suicide (e.g., Virginia Woolf, Sylvia Plath) 4. High productivity and creativity especially in hypomanic state 5. Exuberance, new associations, depth of feelings

With Catatonic Features

1. Motoric immobility or stupor; not responding to instructions; 3. odd, bizarre postures; 4.sometimes echolalia or echopraxia (repeating others speech or movements) 5. .sometimes motionlessness alternates with agitation 6.shut down, won't eat and drink , won't respond, won't bathroom

BIOLOGICAL CAUSES OF BIPLOAR DISORDERS:

1. NEUROTRANSMITER ACTIVITY -That is, low serotonin activity accompanied by low norepinephrine activity may lead to depression; low serotonin activity accompanied by high norepinephrine activity may lead to mania. 2. ION ACTIVITY -Ions seem to play a critical role in relaying messages within a neuron - help transmit messages down the neuron's axon to the nerve endings. -Check book 3. BRAIN STUCUTRE (abnormal brain structure) -For example, the hippocampus, basal ganglia, and cerebellum of these people tend to be smaller than those of other people; they have lower amounts of gray matter in the brain; and their raphe nuclei, striatum, amygdala, and prefrontal cortex have some structural abnormalities

GENETICS OF MOOD DISORDERs

1. No single gene is responsible for any of the mood disorders (polygenic disorders) 1. No single gene, family history 2. Epigenetics Twin studies: 1. If one identical twin has major depressive disorder (MDD) a. there is a 46% chance the other identical twin also has MDD 2. If one fraternal twin has major depressive disorder (MDD) a. there is a 20% chance that the other fraternal twin also has MDD 3. If one identical twin has bipolar I disorder: a. there is a 40% chance that the other identical twin also is bipolar I b. there is an 80% chance that the other identical twin is bipolar I OR has MDD

With Peripartum Onset

1. Onset of symptoms during or after pregnancy 2. Factors predicting postpartum depression 3. Sudden and rapid hormonal switch If have depression higher change of getting peripartum 4. Maybe Genetic 5. There is no joy expecting, there is no responding 6. if you have one postpartum with a child have higher change having with another children and gets worst each time

ONSET, COURSE, PREVALENCE, GENDER DIFFERENCES: BIPOLAR I DISORDER

1. Onset: a. average 18; 50% started by adolescence b. trend: earlier and earlier c. mania rarely starts after age 40 unless prior Hx (= history) of depression a. usually have to look at other things, tumor d. more acute onset than MDD 2. Precursor symptoms: a. labile affect, ADHD-like presentation (temper tantrums, hyperactive, impulsive); anger and violence; high sensitivity; quick to cry, sensitive to a. bipolar sign can sleep less b. criticism and rejection; easily overwhelmed, easily over-stimulated; c. poor sleep pattern, violent nightmares; going through "phases," of low and d. high energy, low and high self-esteem. 3. Course: a. worse with childhood onset b. risk of deterioration without treatment c. pattern may change throughout life d. chronic disorder, but manageable with medication 4. Lifetime Prevalence: a. 1-2% 5. Gender differences: a. 1:1 (female: male) b. males have more manic, females have more depressive episodes

ONSET, COURSE, PREVALENCE, GENDER DIFFERENCES: BIPOLAR II DISORDER

1. Onset: a. average age 22 1. Course: b. may develop into bipolar I disorder 2. Lifetime Prevalence: c. 1-2% 3. Gender differences: b. 1:1 (female: male) c. males have more hypomanic, females more depressive episodes

CYCLOTHYMIC DISORDER

1. Onset: a. teenage years b. onset tends to be slow 2. Course: a. 50% later meet criteria for bipolar I or bipolar II disorder 3. Lifetime Prevalence: a. about 1-2% 2. Gender differences: - 1:1 (female: male)

i. Physical Symptoms (e.g., low energy, decreased appetite, sleep, sex drive, physical pain)

1. Physical pain active out 2. Small pain just become bigger 3. Appetite 4. Can't sleep 5. Energy level 6. Lower sex drive 7. Lack in motivation

With Mixed Features

1. Presence of manic symptoms pointing at possibility of underlying bipolar dis. 2. Feeling mostly depressed but combined with increased energy level, irritability, restlessness, impulsiveness; high risk for suicide! 3. Some anxiety

With Psychotic Features

1. Psychotic symptoms: break with reality; delusions; hallucinations 2. Visual hallucination, voices, death associated hallucinations Always associated with a severe episode, but severe episodes don't have to include psychosis). 3.Goes away once out of depression

With Seasonal Pattern

1. Seasonal Affective Disorder (SAD) 2. Low energy, oversleeping, craving for carbohydrates 3. The light that getting Some getting depression summer 5. Usually more in Alaska or New Hampshire than Florida 5. Hibernating

With Atypical Features

1. Significant weight gain and increase in appetite, 3. hypersomnia; long-standing pattern of interpersonal rejection sensitivity.

SPECIFIERS OF MDD:

1. Single Episode vs. Recurrent Episode - 75% of those who have one episode will have at least one other episode. - If only one episode, it likely was in response to a major life stressor. - Without treatment, an MDD sufferer has on average 5-6 episodes in lifetime. - An untreated major depressive episode lasts 8-10 months. e. Recovery after an episode may be complete or mild depression left. -Dangers of repeated untreated episodes for long-term brain dysregulation. 2. Mild Moderate, Severe MD Episodes 3. With psychotic Features - (hallucination, dilusions) - Only with Psychotic and also with depression and manic depression - Psychotic depression

DSM-5 Criteria for a HYPOMANIC Episode:

1. Types of symptoms are the same as for manic episode, EXCEPT: -Less severe symptoms -Less impairment in social or occupational functioning -No psychotic symptoms - Can be some self of knowlege 2. Hospitalization is NOT needed 3.Symptoms need to last only 4 days before diagnosis can be made

SPECIFIERS FOR BIPOLAR I and BIPOLAR II DISORDER Specifiers that are the same as with MDD:

1. With Psychotic 2. Features (during either the manic or depressed states, or both) 3. With Mixed Features - actually called a "MIXED EPISODE" of bipolar I or II (features of depression in addition to mania,e.g., suicidal, feeling hopeless) 4. With Anxious Distress 5. With Seasonal Pattern 6. With Peripartum Onset

Specifiers of MDD cont.

1. With Psychotic Features 2. With Mixed Features 3. With Anxious Distress 4. With Seasonal Pattern 5. With Peripartum Onset 6. With Atypical Features 7. With Catatonic Features

LIGHT THERAPY

1. for SAD (Seasonal Affective Disorder) 2. light boxes, requiring at least 10,000 lux two hours per day, start small get you out of funk i. reset your eternal clock Increases your serotonin- light /melatonin- in dark 4. Depression causes sleep patterns to be off and do not go into rem as quickly

VNS INFO

1. for treatment-resistant depression (FDA approved in 2005) s2. urgical implantation of a pulse generator in left upper chest; wires go from there into the neck and send mild pulses (every 5 minutes) to the neck's left vagus nerve, and from there to brain areas involved in the regulation of mood, motivation, sleep, appetite, etc. 3. adverse effects: voice alteration or hoarseness 4. Advantages: There is no real big side effects,No being surgery can be taken out, very s Does not interfering with your hormonal or organ system, so good for prengency etc

With Rapid Cycling

1. more than 4 episodes within one year, but usually many more 2. 20% of bipolars are rapic cyclers, 90% of them are women 3. can be precipitated by going off mood stabilizing medication or taking antidepressants only

Additional symptoms that are frequently seen in Mania:

1.Psychosis is common (delusions of grandeur, paranoia, hearing voices) - Hard to know the difference, manic or psychophobia 2. Hypergraphia (writing excessively "of upmost importance") i-Writing more and in the interent in the blog 3. Hyperreligiosity (preaching in public places, writing manifestos) -Becomes very religious 5. Hypersexuality 6. Hyperacuity and/or sharpening of all senses 7. Obsessiveness and compulsions (e.g., ordering, cleaning) 8. High anxiety level - Opersite during depression Intense affect, emotionally reactive 7. Loud speech 8. Self-centeredness, narcissism, manipulation 9. Intrusiveness, meddling 10. Quick to anger, hostility, sometimes violence, enjoys arguing 11. In severe cases: disorganization of thoughts and behavior 12. But also funny, spontaneous, creative

SSRI's (Serotonin Selective Reuptake Inhibitors) (most likely to be proscribe)

A group of second-generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters. -Work by blocking serotonin reuptake Advantages of SSRI's over Tricyclics: (higher change of keep taking) - generally fewer side effects, hence better compliance - less dangerous in overdose - less interaction with alcohol - faster action than tricyclics (2-3 weeks vs. 5-6 weeks) - more effective for OCD features - more effective for sensitivity to rejection better help with those feelings Side effects/problems specific to SSRI's - sexual side effects (delayed orgasm, decreased desire or arousal) - headaches and gastrointestinal problems - sometimes a zombie-like feeling (esp. Paxil) a. get too much serotonin will not go away - elevated suicide risk in that they are very activating a. energy is there but the suicide thoughts are there - increased energy before mood and negative thoughts improve

Deep Brain Stimulation (DBS):

A treatment for depression in which a pacemaker powers electrodes that have been implanted in subgenual cingulate, thus stimulating that brain area.

VAGUS NERVE STIMULATION (VNS)

A treatment for depression in which an implanted pulse genera- tor sends regular electrical signals to a person's vagus nerve; the nerve then stimulates the brain.

ANTIDEPRESSANTS Tricyclics (group

An antidepressant drug such as imipramine that has three rings in its molecular structure. Side effects of Tricyclics 1. weight gain can be helpful with people who loose apatite 2. sedation only good if have anxiety 3. constipation 4. dry mouth 5. more effect with achole Take a long time to work-> 3-4 weeks

MAO Inhibitors (Monoamine Oxidase Inhibitors)

An antidepressant drug that prevents the action of the enzyme monoamine oxidase. -There not proscribe anymore because of these problems but yet always in textbook Problems - They also block same enzymes breaking down serotonin and dopamine they are also breaking down in liver and intestines, causing tyramine build up - Danger of "hypertensive crisis" (stroke, heart attack) - Food (with tyramine) restrictions o Bear, pickles, dark chocolate, cheese, bananas o Commit suicide when eating food - Dangerous interactions with most other medications

NEW DEVELOPMENTS in drug/physical treatments for Depression:

Drugs that suppress stress hormones Drugs working on glutamate, especially Ketamine (an anesthetic and pain reliever with dissociative effects) Anti-inflammatory drugs Exercise (which also reduces inflammation and raises endorphin levels

ONSET, COURSE, PREVALENCE, GENDER DIFFERENCES: PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

Onset: 1. puberty at the earliest Course: 1. likely to vary throughout life cycle Lifetime Prevalence: i. 3- 8% Gender differences: 1. related to levels of female hormones

ONSET, COURSE, PREVALENCE, GENDER DIFFERENCES: MAJOR DEPRESSIVE DISORDER

Onset: onset may be at any age average onset: mid to late 20's trend: earlier and earlier- late 20s but now more early 20s i. average age from period is 8 ii. puberty is earlier 1. Harmons in skin care Course: with each episode, more episodes likely after 3 episodes, life-long MDD likely Lifetime Prevalence: 10-15% Gender differences: 2:1 ratio (female: male)

ONSET, COURSE, PREVALENCE, GENDER DIFFERENCES: PERSISTENT DEPRESSIVE DISORDER (similar to former Dysthymic Disorder)

Onset: onset of chronic low level depression can be early - childhood or teens onset may be slow, starting with milder symptoms any age Course: chronic by definition (at least 2 years of duration) i. rare lasting past 2 years may develop into severe MDD Lifetime Prevalence: 7% Gender differences: 2:1 (female: male)

Anticonvulsants (anti-seizure medication) (preferred, also rapid switch)

Preferred for rapid crying or mixed episodes Preferred if Hx of head injury or drug use Different side effect profile than Lithium

1. MOOD STABILIZERS

Preventive medications, mostly to prevent mania but some effect on depression also Require weeks to build up to therapeutic blood levels May be combined with antidepressants or antipsychotics Sometimes very effective in depressed individuals even without history of mania or hypomania

Lithium (Lithium Carbonate, Li2CO3)

Requires build up in system (about 2 weeks) Narrow therapeutic range (= range in which drug is effective to prevent episodes) Regular blood draws required Danger of kidney toxicity Side effects from Lithium: - fine hand tremors a. looks like drunk - short-term memory impairment - weight gain - possible sedation - toxicity: flu-like symptoms, lack of coordination, confusion

ECT How works

Theory 1: Rewire brain thoughts get negative thoughts into loop and it allows people to take in information that once they could not Theory 2: jump starts brain produce cerotonine, dopamine, norepinephrine, Theory 3: resetting circadian rhythms

NEWER ANTIPSYCHOTICS

When somebody is in mania then mood stabilizers won't start working so also gibe antipsychotics E.g., Abilify, Zyprexa, Risperdal, Seroquel, Latuda To treat psychosis in both manic and depressive episodes To bring down mania quickly Newer antipsychotics also have some mood-stabilizing properties As an "augmentation strategy" (together with antidepressant) for treating depression Side effects to be discussed later (with schizophrenia)

1. MAJOR DEPRESSIVE DISORDER (MDD) DSM-5 Definition of "Major Depressive Episode":

a. A severe pattern of depression that is disabling and is not caused by such factors as drugs or a general medical condition. b. A person with a severe depressive episode will have a greater chance of having other one in their life 75% 1. For at least two weeks, at least 5 of the following 9 symptoms have to me met.

DSM-5 Criteria for a MANIC Episode:

a. Abnormally high energy level representing increase of normal energy level b. Abnormally and persistently elevated, expansive, or irritable mood - Undiagnosed fly off handle but really bipolar c. at least 3 of the following 7: d. Symptoms last one week OR Hospitalization is needed

Biochemical Factors aka nephron and serotonin

a. norepinephrine A neurotransmitter whose abnormal activity is linked to depression and panic disorder. b. serotonin A neurotransmitter whose abnormal activity is linked to depression, obsessive- compulsive disorder, and eating disorders. a. Low activity of two neurotraumatic chemicals, norepinephrine and serotonin has effect on unipolar depression. b. First medication researchers that thigh blood pressure often caused depression because it lowed norepinephrine and serotonin c. Antidepressant first true drug that work because norepinephrine and /or serotonin

BIPOLAR I DISORDER

bipolar I disorder A type of bipolar disorder marked by full manic and major depressive episodes 1. At least one manic episode 2. Usually mania alternates with major depression BUT for there may or may not be depression to meet criteria for Bipolar I Disorder (Most severe type)

BIPOLAR II DISORDER

bipolar II disorder A type of bipolar disorder marked by mildly manic (hypomanic) episodes and major depressive episodes. 1. For a least 2 years, periods of hypomania symptoms and depressive symptoms. 2. Depressive symptoms are milder than with Bipolar II disorder.

1.4 SNRI's (Serotonin-Norepinephrine Reuptake Inhibitors) (combo drugs)

block reuptake of both norepinephrine and serotonin

NDRI's (Norepinephrine-Dopamine Reuptake Inhibitors) (increase dopamine leves)

blocks reuptake of mostly dopamine and also norepinephrine also is a nicotine antagonist (Zyban) helps get off with nicotine risks include lowered seizure threshold no weight gain, no decrease in sexual functioning, very activating helpful with attention deficit/hyperactivity disorder sometimes help with HDHD helpful with former stimulant abusers less effective for anxiety or may even cause anxiety, not useful for panic and OCD because increase serotonin

CYCOLOTHYMIA

cyclothymic disorder A disorder marked by numerous periods of hypomanic symptoms and mild depressive symptoms. 1. For a least 2 years, periods of hypomania symptoms and depressive symptoms. 2. Depressive symptoms are milder than with Bipolar II disorder.

ECT (Electroconvulsive Therapy)

electroconvulsive therapy (ECT) A treatment for depression in which electrodes attached to a patient's head send an electrical current through the brain, causing a convulsion. Often after ECT medication start working

TMS What is it?

electromagnetic coil is held against patient's scalp that emits powerful magnetic pulses to alter brain activity gives currents into prefrontal cortex where the underactive in depressed people

For at least two weeks, at least 5 of the following 9 symptoms have to me met.

i. At least one of the two first listed symptoms have to be present. ii. Depressed mood most of the day iii.Diminished interest or pleasure in almost all activities previously enjoyed iv. (anhedonia) someone who cannot experience pleasure - Especially to previous pleasure, marked difference v. Significant weight loss or weight gain, or significant change in appetite -Loose taste -Craving of carbs vi. Insomnia or hypersomnia - Sleep is disturbing a. Waking up in the morning, toss and turn, b. Internal clock does not work - Hypersomnia- Oversleep vii. Psychomotor retardation or psychomotor agitation, nearly every day -Agitation, and anxiety will pressure you to try or think about suicided viii. Diminished ability to concentrate or indecisiveness ix. Fatigue or loss of energy nearly every day x. Feelings of worthlessness of inappropriate guilt - More in the US because self-made person, positive thoughts then it is ur fault -Guilt worthless, function, and in our individual society xi. Recurrent thoughts of death and/or suicidal ideation

a. Diagnosing depression in the elderly (depression vs. dementia)

i. In older people memory problems are more possible so often depression is misdiagnosis ii. Depressed people are aware that their memory is not as sharp as it is and hard time finding words iii. Dementia underestimate their impairment iv. Depression overestimate their impairment v. When she could she was in depression she couldn't talk but when vi. Physical pain increase the depression in elderly

a. Diagnosing depression in children and adolescents (watch for "acting out" behaviors)

i. Kids acting out and feeling bad, self a steam ii. Teenager hormonal places a great rolealso acting out

DEPRESSIVE DISORDERS a. Depression is a "Spectrum Disorder"

i. Spectrum from feeling blue all the way to psychotic or suicidal depression. 1. Various types of depression 2. Take you hope and good times

Advantages of TMS

l1. ess intrusive, 2. No hospitalization, no surgery, anthesis 3. Outpatient basis takes 40 min 4. No massive headacts 5. ADA approve 6. Works better with younger people

PERSISTENT DEPRESSIVE DISORDER (similar former Dysthymia)

persistent depressive disorder A chronic form of unipolar depression marked by ongoing and repeated symptoms of either major or mild depression.

.PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

premenstrual dysphoric disorder A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation. 1. Marked change in mood during a woman's premenstrual period. 2. Moods changed suddenly feeling better (This diagnostic category was only in the appendix of DSM-IV and is now an accepted diagnosis.)

TRANSCRANIAL MAGNETIC STIMULATION (TMS):

transcranial magnetic stimulation (TMS) A treatment in which an electromagnetic coil, which is placed on or above a patient's head, sends a current into the individual's brain. Other biological treatment and same reasons as ECT- medication does not work, treatment resistance depression , successful in OCD, depersonalization disorder/ distortive disorder