Tag: HYT Module

Psychotherapy

PSYCHOTHERAPY


PSYCHOTHERAPY

  • Treatment of psychiatric disorders by using psychological methods.
  • Most important method – Behavior therapy.

Behavior therapy:

  • Psychological treatment where patient’s maladaptive behaviors changed to improve quality of life.
  • “Behavior therapy” is generic term – Used to describe a variety of specific techniques intended to remove maladaptive behaviors. 

Techniques of behavior therapy: 

  • Systematic desensitization.
  • Therapeutic graded exposure or in vivo exposure (or exposure & response prevention)
  • Flooding (Implosion).
  • Modeling (Participant modeling).
  • Assertiveness training.
  • Social skills training.
  • Aversive conditioning (Aversion therapy).

Systemic desensitization:

  • Based on “reciprocal inhibition” principle.
  • According to this principle, f anxiety-provoking stimulus provided while a person is in relaxed state, the anxiety gets inhibited.
  • Used in treatment of phobias, obsessive-compulsive disorders & certain sexual disorders.

Therapeutic graded exposure or in vivo exposure (or exposure & response prevention):

  • Similar to systematic desensitization except that no relaxation techniques used & real-life situations used.
  • Used in phobias & obsessive-compulsive disorder.

Flooding (Implosion):

  • Patient made to confront feared situation directly, without any hierarchy (as in systematic desensitisation or graded exposure & no relaxation exercises used).

Modeling (Participant modeling):

  • Therapist himself makes contact with phobic stimulus & demonstrates patient.
  • Patient learns by imitation & observation.

Assertiveness training:

  • Person is taught to be assertive (asking for his rights & refusing unjust demands of others).

Social skills training:

  • Involves imparting skills required for dealing with others & living a social life.
  • Used in schizophrenia.

Aversive conditioning (Aversion therapy):

  • Clinical use of classical conditioning principle.
    • An association created between unwanted behavior & painful stimuli —> unwanted behavior ceases.
  • Now rarely used due to ethical considerations.
  • Used for unwanted behaviors treatment (paraphilias).

Indications for behavior therapy:

  • Primarily in anxiety disorders treatment (like phobia, panic disorders).
  • Also used in depression, dissociative disorders, eating disorders, sexual disorders, personality disorders, substance used disorders & schizophrenia.

Exam Important

  • Most important method in psychotherapy is behavior therapy.
  • Techniques used in behavious therapy includes Systematic desensitization, therapeutic graded exposure or in vivo exposure (or exposure & response prevention), flooding (Implosion), modeling (participant modeling), assertiveness training, social skills training & aversive conditioning (aversion therapy).
  • Systemic desensitization is based on “reciprocal inhibition” principle.
  • Systemic desensitization used in treatment of phobias, obsessive-compulsive disorders & certain sexual disorders.
  • Therapeutic graded exposure is also referred as in-vivo exposure/exposure & response prevention.
  • Exposure & response prevention is used in phobia treatment.
  • Aversive conditioning is used for unwanted behaviors treatment (paraphilias).
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Death & Dying

DEATH & DYING


DEATH & DYING

  • Is a series of responses in an iindividual after informing about his impending death.
  • 3 stages of death and dying were proposed by Elizabeth Kubler-Ross.

Stage 1 – Denial and shock:

  • Characterized by refusal to accept diagnosis & reaction of shock.
  • Stage 2: Anger.
  • Stage 3: Bargaining.
  • Stage 4: Depression.
  • Stage 5: Acceptance.

Grief, bereavement & mourning:

Bereavement:

  • State of being deprived of someone due to death.

Grief:

  • Is psychological feeling precipitated by death of a loved one.

Mourning:

  • Process by which grief is resolved.
  • Involves societal practices like funerals, burial & memorial services.

Exam Important

  • 3 stages of death and dying were proposed by Elizabeth Kubler-Ross.
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Adjustment Disorder

ADJUSTMENT DISORDER


ADJUSTMENT DISORDER

  • Disorders characterized by emotional responses to stressful events like financial problems, medical illness, relationship problems or death of a loved one.

Symptoms:

  • Symptom complex includes anxiety & depressive symptoms.
  • Depressed mood
  • Worry
  • Feeling of inability to cope.
  • Disturbance in individuals daily functioning.

Differential diagnosis:

Depression – 

  • Depression follows negative life event.
  • Differentiated by delineating uncomplicated bereavement/grief reactions.

In uncomplicated bereavement:

  • Symptoms & dysfunctions developing are within expected limits.

In adjustment disorder:

  • Symptoms & dysfunction are beyond expectable reaction to stressor.

Other differential diagnosis:

  • PTSD
  • Brief psychotic disorders.
  • Diagnoses should be given precedence if their diagnostic criterion are met, irrespective of stressors presence.

Treatment:

  • Psychotherapy – Treatment of choice.
    • Supportive psychotherapy commonly used.

Medications

  • Adjuvant to psychotherapy.
  • Antidepressants & antianxiety drugs.

Exam Important

  • Disorders characterized by emotional responses to stressful events like financial problems, medical illness, relationship problems or death of a loved one.
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Bipolar Disorders

BIPOLAR DISORDERS


BIPOLAR DISORDERS

  • Characterized by episodes of both mania & depression.
  • Equally prevalent in men & women.
    • Manic episodes – More common in men; depressive episodes – More common in women.
    • More commonly seen in divorced and single persons.
  • Onset age – 30 yrs (average). 
Causes:

Neurotransmitters:

  • Increased dopamine levels for manic episode.

Genetic factors:

  • Chromosomes 18q & 22q – Strongest evidence linked to bipolar disorder.
  • Chromosome 21q involved.

Subtypes:

  • Bipolar 1/2 = Schizobipolar disorder (schizoaffective disorder)
  • Bipolar I = Mania with depression (or mania alone).
    • Bipolar I 1/2 = Depression with protracted hypomania.
  • Bipolar ll = Depression with discrete hypomanic episodes.
    • Bipolar ll 1/2 = Depression superimposed on cyclothymia.
  • Bipolar lll = Depression plus induced hypomania 
    • (e.g. hypomania occurring solely in association with antidepressants or other somatic treatment.
    • Bipolar lll 1/2 = Bipolar disorder associated with substance use
  • Bipolar lV = Depression superimposed on hyperthymic temperament.

Symptoms:

Symptoms of manic episode:

  • Elevated mood – Undue happiness or irritable mood.
  • Increased self-esteem or grandiosity.
  • Decreased need for sleep (e.g. patient feels rested after 2 hours of sleep)
  • Over-talkativeness.
  • Flight of ideas.
  • Distractibility (not able to concentrate on task in hand).
  • Increased goal-directed activities (overactivity, hypersexuality overfamiliarity).
  • Psychomotor agitation.

Diagnostic criteria:

  • Symptoms should last for at least 7 days.
  • Must cause marked impairment in social & occupational functioning.

Psychotic symptoms:

  • Delusions & hallucination.
  • Maybe mood congruent (delusion of grandiosity)/incongruent (delusion of persecution).

Diagnostic criteria:

  • Must exhibit manic episode with psychotic symptoms.

Hypomania:

  • Symptoms similar to mania with lesser severity & reduced social & occupational functioning impairment.
  • Duration criterion = 4 days.

Mixed episodes:

  • Presents with both manic & depressive symptoms.
  • Duration = Min. 7 days.

TREATMENT:

  • Mood stabilizer: Lithium (prototyplcal mood stabilizer), valproate, carbamazepine, oxcarbazepine & lamotrigine (For bipolar depression).
  • Antipsychotics.
  • Benzodiazepines (lorazepam & clonazepam) – Used in acute mania due to their calming effect.
  • Antidepressants – Only as combination drug.

Exam Important

  • Chromosomes 18q & 22q have strongest evidence linked to bipolar disorder.
  • Symptoms of manic episode includes distractibility, flight of ideas & decreased need for sleep.
  • Diagnostic criteria for manic episode is that symptoms should last for at least 7 days.
  • Lithium is considered “prototypical mood stabilizer”.
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Suicide – Psychiatric Inputs

SUICIDE – PSYCHIATRIC INPUTS


SUICIDE – PSYCHIATRIC INPUTS

Cause:

  • Low CSF levels of 5-hydroryindoleacetic acid (5 HIAA).
  • 5-hydroryindoleacetic acid (5 HIAA)- Serotonin metabolite associated with higher suicide risk.

Psychiatric illnesses & suicide risks:

  • Depressive disorder
  • Schizophrenia
  • Alcohol dependence & other substance dependence.
  • Personality disorders (especially borderline personality disorder & antisocial personality disorder).

Suicidal risk factors:

  • Male sex
  • Age > 45 years
  • Divorced, widowed
  • Unemployed
  • Chronic illness
  • Family history of suicide
  • Poor social support.

Exam Important

  • Lower levels of 5-hydroryindoleacetic acid (5 HIAA), a serotonin metabolite is associated with higher suicide risk.
  • Males are more prone to have suicidal risk.
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Lithium – Psychiatric Usage

LITHIUM – PSYCHIATRIC USAGE


LITHIUM – PSYCHIATRIC USAGE

Indications of lithium in psychiatric disorders:

  • Used for treatment of acute episodes (both mania & depression).
    • Effective treatment for acute mania – Effective serum concentration for acute mania treatment is 1.0-1.5 mEq/ dl.
  • Antimanic efficacy of lithium is more than its antidepressive efficacy.
  • Prophylaxis in bipolar disorder.
  • Maintenance treatment with lithium decreases frequency, severity & duration of manic & depressive episodes in patients with bipolar disorders.
    • Serum concentration required for maintenance treatment is 0.6-1.2 mEq/dl.
  • In schizoaffective disorders.
  • As an adjuvant to antidepressants in major depressive disorder.

Other uses:

  • Obsessive-compulsive disorder
  • Aggression
  • Headache (cluster, migraine)
  • Gout
  • Epilepsy
  • Movement disorders
  • Neutropenia
  • Ulcerative colitis.

Exam Important

  • Lithium is used in effective treatment for acute mania & its effective serum concentration is 1.0-1.5 mEq/ dl.
  • Serum lithium concentration required for maintenance treatment is 0.6-1.2 mEq/dl.
  • Lithium is also used for headache (cluster, migraine) & neutropenia.
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Extrapyramidal Side Effects

EXTRAPYRAMIDAL SIDE EFFECTS


EXTRAPYRAMIDAL SIDE EFFECTS

  • Caused by antipsychotics.
    • More common with high-potency typical antipsychotics (compared to atypical antipsychotics).
  • Various movement disorders caused are collectively referred to as “extrapyramidal symptoms/extrapyramidal side effects”.

Mechanism:

  • Due to dopamine receptor blockade in nigrostriatal tract (neural pathway from substantia nigra to striatum).

TYPES OF MOVEMENT DISORDERS:

  • Acute dystonia.
  • Acute akathisia
  • Drug-induced parkinsonism
  • Tardive dyskinesia
  • Neuroleptic malignant syndrome

1. Acute dystonia:

  • Earliest side effect.
  • Occurs within minutes (more with injectable antipsychotic).

Features:

  • Characterized by sudden contraction of muscle group –
  • Symptoms like torticollis, trismus (contraction of jaw muscles), eyeballs deviation (oculogyric crisis due to extraocular muscle contraction) & laryngospasm.

Management:

  • Immediate administration of parenteral anticholinergicsa (benztropine, promethazine or diphenhydraminea).
  • Prevent prophylactic use of oral anticholinergics during typical antipsychotics prescription.

2. Acute akathisia:

  • Commonest side effect of antipsychotics.

Features:

  • Characterized by an inner sense of restlessness along with objective.
  • Observable movements (fidgeting of legs, pacing around, inability to sit or stand in one place for a long time).

Management:

  • Beta-blockers (propranolol DOC)
  • Anticholinergics
  • Benzodiazepines.
  • Prevented by changing to 2nd generation or low potency 1st-generation antipsychotics (lesser incidence of akathisia).

3. Drug induced parkinsonism:

Features:

  • Characterized by triad – Rigidity, bradykinesia & resting tremors.

Management:

  • Anticholinergics.
  • Changing to 2nd gen. antipsychotics or low-potency 1st gen. antipsychotics.
  • Dose reduction can be tried.
  • Prevented by prophylactic anticholinergic use.

4. Tardive dyskinesia:

  • “Tardive” refers to features developing after prolonged exposure.
  • Tardive dyskinesia develops after long-term antipsychotics treatment.

Features:

  • Involuntary movements of tongue (e.g. twisting, protrusion), jaw (e.g. chewing), lips (e.g. smacking, puckering), trunk or extremities.
  • Rapid, jerky movements (choreiform movements) or slow, sinusoid movements (athetoid movements).

Management:

  • Change to 2nd gen. antipsychotics.

5. Neuroleptic malignant syndrome: 

  • Fatal side effect of antipsychotics.

Features: 

  • Characterized by,
    • Muscle rigidity.
    • Elevated temperature (greater than 38°C). Increased CPK (creatine phosphokinase) levels.

Other symptoms: 

  • Diaphoresis, tremors, confusion, autonomic disturbances, liver enzyme elevation & leukocytosis.

Mechanism: 

  • D2 antagonism at various levels.
  • D2 receptors blockade in corpus striatum→ Causes muscle contraction & rigidityInitiating heat generation.
  • Continuing muscle damage→ Result in myoglobinuria & renal failure.
  • D2 receptors blockade in hypothalamus interferes with heat regulation.
  • D2 receptors blockade of spinal neurons causes autonomic disturbances.
    • Increased CPK indicates muscle injury.

Management:

  • Early recognition of symptoms & prompt withdrawal is paramount importance.

Treatment:

  • Skeletal muscle relaxants (dantrolene).
  • Dopamine agonists (amantadine & bromocriptine).

Supportive measures:

  • Adequate hydration.
  • During antipsychotics treatment is restarted – 2nd gen. antipsychotics should be used.

NOTE: ALL EXTRAPYRAMIDAL SIDE EFFECTS ARE ALSO CAUSES BY ATYPICAL ANTI-PSYCHOTICS BUT WITH LESSER INCIDENCE.

Exam Important

  • Extrapyramidal side effects are caused by antipsychotics.
  • Extrapyramidal side effects by antipsychotics are due to dopamine receptor blockade in nigrostriatal tract.
  • Extrapyramidal side effects are more common with high-potency typical antipsychotics (compared to atypical antipsychotics).
  • Types of movement disorders includes acute dystonia, acute akathisia, drug-induced parkinsonism, tardive dyskinesia & neuroleptic malignant syndrome.
  • Acute dystonia is the earliest side effect.
  • Acute dystonia is characterized by torticollis, trismus (contraction of jaw muscles).
  • Immediate administration of parenteral anticholinergicsa (benztropine, promethazine or diphenhydraminea) is used for managing acute dystonia.
  • Acute akathisia is commonest side effect of antipsychotics.
  • Acute akathisia is characterized by observable movements (fidgeting of legs)
  • DOC for acute akathisia is beta-blockers (propranolol).
  • Tardive dyskinesia develops after long-term antipsychotics treatment.
  • Neuroleptic malignant syndrome is a fatal side effect of antipsychotics.
  • Neuroleptic malignant syndrome is characterized by muscle rigidity, elevated temperature (greater than 38°C) & increased CPK (creatine phosphokinase) levels.
  • Skeletal muscle relaxants (dantrolene) is used for management of neuroleptic malignant syndrome.
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Depression – Introduction & Symptoms

DEPRESSION – INTRODUCTION & SYMPTOMS

Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Ans. A

Explanation:

Female REF: Kaplan and sadock’s synopsis in psychiatry 10th ed p. 529

Risk factors of suicide in depression are:

  • At end( involutional) or beginning of depression
  • Mood disorders , personality disorders , psychosis , hypochondriac
  • >45yrs male, unemployed, single, divorced, chronically ill, widowed, recently bereaved
  • Family history

Q. 2

Schizophrenia and depression both have A/E 

 A

Formal thought disorder

 B

Social withdrawal

 C

Poor personal care

 D

Decreased interest in sex

Q. 2

Schizophrenia and depression both have A/E 

 A

Formal thought disorder

 B

Social withdrawal

 C

Poor personal care

 D

Decreased interest in sex

Ans. A

Explanation:

A i.e. Formal thought disorder


Q. 3

Most common age for depression is

 A

Middle age men

 B

Middle age female

 C

Young girl

 D

Children

Q. 3

Most common age for depression is

 A

Middle age men

 B

Middle age female

 C

Young girl

 D

Children

Ans. B

Explanation:

B i.e. Middle age female

Quiz In Between


Q. 4

Neurotransmittors involved in depression are 

 A

GABA and Dopamine

 B

Serotonin and Norepineprine

 C

Serotonin and Dopamine

 D

Norepinephrine and GABA

Q. 4

Neurotransmittors involved in depression are 

 A

GABA and Dopamine

 B

Serotonin and Norepineprine

 C

Serotonin and Dopamine

 D

Norepinephrine and GABA

Ans. B

Explanation:

B i.e. Serotonin & Noradrenaline (Nor epinephrine)


Q. 5

Endogenous Depression is characterized by A/E

 A

Loss of Self esteem

 B

Guilt psychosis

 C

Third person hallucination

 D

Paranoid feeling

Q. 5

Endogenous Depression is characterized by A/E

 A

Loss of Self esteem

 B

Guilt psychosis

 C

Third person hallucination

 D

Paranoid feeling

Ans. C

Explanation:

C i.e. Third person hallucination


Q. 6

Suicide risk is common with which type of depression :

 A

Reactive depression

 B

Endogenous depression

 C

Endogenous depression

 D

All

Q. 6

Suicide risk is common with which type of depression :

 A

Reactive depression

 B

Endogenous depression

 C

Endogenous depression

 D

All

Ans. B

Explanation:

B i.e. Endogenous depression

Quiz In Between


Q. 7

Most common symptom of depression in India is:

March 2011

 A

Low mood

 B

Sleep disturbances

 C

Vague body aches

 D

Suicidal tendencies

Q. 7

Most common symptom of depression in India is:

March 2011

 A

Low mood

 B

Sleep disturbances

 C

Vague body aches

 D

Suicidal tendencies

Ans. C

Explanation:

Ans. C: Vague body aches

Multiple physical symptoms (such as heaviness of head, vague body aches) are particularly common in the elderly depressives and depressed patients from the developing countries (such as India)

Depression:

  • MC psychiatric disorder in India: Depression
  • Neurotransmitter involved: Serotonin and nor-epinephrine
  • MC cause of suicide: Depression
  • Risk features of suicide in depression:

— Endogenous type of depression

— Psychotic depression

  • MC type of post-purpueral psychosis: Depression
  • Nihilistic ideas: Seen in depression

Q. 8

Depression of consciousness level in hypothermia starts when the core body temperature falls below:

COMEDK 14

 A

35°C

 B

34°C

 C

33°C

 D

32°C

Q. 8

Depression of consciousness level in hypothermia starts when the core body temperature falls below:

COMEDK 14

 A

35°C

 B

34°C

 C

33°C

 D

32°C

Ans. D

Explanation:

Ans. 32°C


Q. 9

Major depression is diagnosed after minimum of:

Maharashtra 09

 A

1 week

 B

2 weeks

 C

3 weeks

 D

4 weeks

Q. 9

Major depression is diagnosed after minimum of:

Maharashtra 09

 A

1 week

 B

2 weeks

 C

3 weeks

 D

4 weeks

Ans. B

Explanation:

Ans. 2 weeks

Quiz In Between


Q. 10

The evidence-based psychological therapy of choice for depression is.

 A

Group discussion therapy

 B

Counselling

 C

Cognitive behaviour therapy

 D

Psychological psychotherapy

Q. 10

The evidence-based psychological therapy of choice for depression is.

 A

Group discussion therapy

 B

Counselling

 C

Cognitive behaviour therapy

 D

Psychological psychotherapy

Ans. C

Explanation:

Ans. c. Cognitive behaviour therapy

The evidence-based psychological therapy of choice for depression is cognitive behaviour therapy.

“Cognitive Behavioral Therapy (CBT) developed by Aron Beck, is an extremely useful and evidence based non pharmacological intervention for depression. This therapy involves identification of the cognitive errors (thinking errors) in an individual and replacing the same with alternative thoughts, which are more adaptive and healthy in nature. It is most useful in patients suffering from mild to moderate depression.”- Kaplan and Sadock 10/e pe p553

Cognitive (Behaviour) Therapy

  • It was developed by Beck and Meichenbaum, for the treatment of depression°, anxiety disorder°, panic disorder°, phobias°, eating disorders°, anticipatory anxiety°, and also for teaching problem solving skills° (methods).
  • It involves:
  • Cognitive techniques (e.g. recognizing and correcting negative thoughts, teaching reattribution techniques, increasing objectivity in perceptives, identifying and testing maladaptive assumptions, and decentering) Behaviour techniques (activity scheduling, homework assignment, graded task assignment, behavioral rehearsal, role playing, and diversion technique)

Q. 11

Treatment for unipolar depression is ‑

 A

Fluoxetine

 B

Sertaline

 C

Citaloprom

 D

All of the above

Q. 11

Treatment for unipolar depression is ‑

 A

Fluoxetine

 B

Sertaline

 C

Citaloprom

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e., All of the above

  • All the given drugs are SSRI antidepressants.

Antidepressants

  • Typical

a. Tricyclic antidepressants

  1. NA + 5HT reuptake inhibitors:- Imipramine, Trimipramine, Amitriptyline, Clomipramine.
  2. Predominantly NA reuptake inhibitors:- Desipramine, Nortriptyline, Amoxapine, Reboxetine.

b. Selective serotonin reuptake inhibitors:- Fluoxetine, Paroxetine, Sertaline, Citalopram, Scitalopram.

B. Atypical :- Trazodone, Mianserine, Mitrazapine, Venalafaxin, Duloxetine, Tianeptine, Amineptine, Bupropion.

C. MAO inhibitors :Tranylcypramine, Meclobemide, Clorgyline


Q. 12

All are required to diagnose major depression except ‑

 A

Depressed mood

 B

Isomnia

 C

Nihlistic ideas

 D

Decreased concentration

Q. 12

All are required to diagnose major depression except ‑

 A

Depressed mood

 B

Isomnia

 C

Nihlistic ideas

 D

Decreased concentration

Ans. C

Explanation:

Ans. is ‘c’ i.e., Nihlistic ideas

Diagnostic criteria for major depression

  • 5 or more of following symptoms should be present most of the day for at least 2 weeks: ‑
  1. Depressed mood
  2. Loss of interest or pleasure in all activities.
  3. Decrease/increase appetite or loss/gain of weight.
  4. Insomnia or hypersomnia (Increased or decreased sleep).
  5. Psychomotor retardation or agitation (decreased or increased psychomotor activity).
  6. Fatigue or loss of energy (weakness or lethargy).
  7. Feelings of worthlessness or excessive guilt.
  8. Diminished concentration
  9. Recurrent thoughts of death or recurrent suicidal ideation or suicidal attempt.
  • At least one of symptoms should be either :‑
  1. Depressed mood or 2) Loss of interest or pleasure —) These two (1 & 2) are essential criteria. Therefore 1 essential criterian and 4 other criteria (total 5) should be persent.

Quiz In Between


Q. 13

Classical triad of symptoms of depression includes all except ‑

 A

Depressed mood

 B

Slowed thinking

 C

Distractibility

 D

Psychomotor retardation

Q. 13

Classical triad of symptoms of depression includes all except ‑

 A

Depressed mood

 B

Slowed thinking

 C

Distractibility

 D

Psychomotor retardation

Ans. C

Explanation:

Ans. is ‘c’ i.e., Distractibility

Clinical features of depression

  • The classical triad of depression is depressed mood, psychomotor retardation, and slowed-down thinking.
  1. Mood : Mood is characteriztically low and sad. There is loss of interest and pleasure in almost all activities, which result in social withdrawal, avolition,occupational dysfunction. In severe cases there may be anhedonia (inability to experience pleasure).
  2. Thoughts (Thinking) : – Pesimistic thoughts conerning the patients past, present and future occur which results in Hopelessness, Helplessness, and worthlessness. Other thought problems may be guilt-feeling, Loss of self esteem, Suicidal ideas, Delusion of nihlism (World has come to an end, Intestines has been rotated away, No brain in head), Hypochondriacal delusions [Patient believes that he has severe (cancer) or incurable disease (eg. AIDS)]. Other delusions that may occur in elderly include paranoid or persecutory delusion, and delusional jealousy.
  3.  Psychomotor activity : – There is psychomotor retardation —> Movements are sluggish & laboured, lack of initiative & energy, Easy fatiguability. In severe form, the patient becomes stuporous (depressive stupor). In older patient there may be agitation and restlessness.
  4. Cognition : – There is poor concentration, which may lead the patient to think (mistakenly) that the memory is also impaired (However, memory is normal). In old patients depression may present similar to dementia, i.e., Pseudodementia.
  5. Somatic symptoms & biological disturbances : – Multiple physical symptoms are common in elderly patient. Symptoms include heaviness of head, generalized ache & pain, Loss of sexual drive and amenorrhea, severe disturbance in biological function is called somatic syndrome (melancholia). Somatic syndrome (melanocholia) is characterized by :-
  • Decrease in appetite or weight
  • Early morning awakening, at least 2 hours before usual time.
  • Diurnal variation, depession is worse in morning
  • Loss of interest and loss of reactivity to pleasurable stimuli, and loss of pleasure in all activities.
  • Psychomotor agitation or retardation.
  • Excessive or inappropriate guilt.

6. Psychotic symptoms (Psychotic depression) : – Occur in 15-20% of patients. Symptoms include 2″a person auditory hallucinations, delusions, grossly inappropriate behavior. These symptoms may be mood congruent (e.g., nihilistic delusions, delusions of poverty or guilt) which are understandable in the light of depressed mood or can be mood incongruent (e.g., delusion of control) which are not directly related to depressive mood. Psychotic depression usually occur later in life and is associated with severe depression.


Q. 14

Intense depression & misery without any cause is?

 A

Melancholia

 B

Major depressive disorder

 C

Mania

 D

Schizophrenia

Q. 14

Intense depression & misery without any cause is?

 A

Melancholia

 B

Major depressive disorder

 C

Mania

 D

Schizophrenia

Ans. A

Explanation:

Ans:A. Melancholia


Q. 15

Depression is associated with which of the following neurological condition ‑

 A

Cerebro-vascular disorder

 B

Multiple sclerosis

 C

Epilepsy

 D

None of the above

Q. 15

Depression is associated with which of the following neurological condition ‑

 A

Cerebro-vascular disorder

 B

Multiple sclerosis

 C

Epilepsy

 D

None of the above

Ans. A

Explanation:

Ans. is ‘a’ i.e. Cerebro-vascular disorder

[Ref: Oxford Textbook of Stroke and Cerebrovascular Disease p. 2461]

important causes of depression

  • General medical/neurological/endocrine disorders: – Cerebrovascular disorders, CNS infection, Parkinson’s disease, Dementia (Alzheimer’s disease), Hyperthyroidism, Hypothyroidism,Cushing’s disease or Addison’s disease, Hypopituitarism, Acromegaly, Hyperparathyroidism, Hypoparathyroidism, Postpartum period, Menses related disorders, Cancer, Tuberculosis

Quiz In Between


Q. 16

Beck’s cognitive triad of depression includes :

 A

Self

 B

Future

 C

Past experience

 D

World and environment 

Q. 16

Beck’s cognitive triad of depression includes :

 A

Self

 B

Future

 C

Past experience

 D

World and environment 

Ans. A:B:D

Explanation:

Ans. A,Self B,Future & D,World and environment 

  • Aaron Beck postulated a cognitive triad of depression.

Consists of,

  • Views about tlw self-a negative self precept.
  • About environment-a tendency to experience the world as hostile and.demanding.
  • About future – expectation of suffering and failure.

Therapy consists of modifying these distortions.

  • Cognitive triad :Beliefs about oneself, the world, and the future.

Q. 17

Essential criteria for major depression are all except –

 A

Delusion of grandeur

 B

Loss of pleasure

 C

Insomnia

 D

Hypersomnia

Q. 17

Essential criteria for major depression are all except –

 A

Delusion of grandeur

 B

Loss of pleasure

 C

Insomnia

 D

Hypersomnia

Ans. A

Explanation:

Ans. A. Delusion of grandeur

[Ref Niraj Ahaia p. 7l-72; Keplarn and Sadsck  p. 357]

Diagnostic criteria for major depression

  • 5 or more of the following symptoms should be present most of the day for at least 2 weeks: –
  • Depressed mood
  • Loss of interest or pleasure in all activities.
  • Decrease/increase appetite or loss/gain of weight.
  • Insomnia or hypersomnia (Increased or decreased sleep).
  • Psychomotor retardation or agitation (decreased or increased psychomotor activity).
  • Fatigue or loss of energy (weakness or lethargy).
  • Feelings of worthlessness or excessive guilt.
  • Diminished concentration
  • Recurrent thoughts of death or recurrent suicidal ideation or suicidal attempt.

Quiz In Between



Depression – Introduction & Symptoms

DEPRESSION – INTRODUCTION & SYMPTOMS


DEPRESSION – INTRODUCTION & SYMPTOMS

INTRODUCTION:

  • One of commonest psychiatric disorder.
  • Responsible for maximum DALYs (disability-adjusted life years) amongst all psychiatric disorders.
  • Most common cause of suicide.
  • Characterized by major depressive episodes in absence of any manic, mixed or hypomanic episodes.

EPIDEMIOLOGY:

  • Lifetime prevalence = 17%
  • More prevalent in women (Middle-aged)
    • Mean onset age – 40 years.
  • More commonly in divorced & separated persons.

CAUSES:

Biological factors – 

  • Neurotransmitters disturbance (Decreased levels of serotonin & norepinephrine).
  • Hormonal disturbance (Elevated HPA activity (hypothalamic-pituitary-adrenal axis activity) & hypothyroidism).
  • Neuroanatomical consideration – Decreased activity in dorsolateral prefrontal cortex & increased activity in amygdala).
  • Genetic factors – Element binding protein (CREB 1)on chromosome 2.

Psychological theories –

  • Cognitive theory – 
  • Cognitive triad of depression – Negative view of self (ideas of worthlessness), negative views about environment (ideas of helplessness) & negative view about future (ideas of hopelessness).
  • Learned helplessness.

SYMPTOMS:

  • Pneumonics = SIGECAPS.

1. Sleep disturbances:

  • Insomnia & sometimes hypersomnia.
  • Characteristic sleep pattern – Early morning awakening & reduced latency of REM sleep.

2. Interest (Loss)/anhedonia:

  • Loss of interest in activities which interests patient before.

3. Guilt: 

  • Excessive guilt feelings.
  • Blaming himself for trivial matters.

4. Energy (lack): 

  • Decreased energy levels.
  • Ea
  • sy fatigability.

5. Cognition/Concentration:

  • Negative cognitions (thoughts).
  • Poor concentration.

6. Appetite:

  • Loss of appetite & weight loss (usually).
  • Sometimes weight gain also.

7. Psychomotor agitation or retardation:

  • Psychomotor – Changes in motor activity secondary to psychological causes.
  • Increased activities (restlessness) or decreased (dormant activities).

8. Suicidal thoughts.

9. Sadness of mood (depressed mood).

SPECIAL FEATURES IN DEPRESSION:

Psychotic features

  • Severe depression patients present with psychotic symptoms (delusions & hallucinations) – Referred as “psychotic depression”.
  • Psychotic symptoms are mood congruent (content of delusion) or nihilistic delusion.

Atypical features:

  • Presents reverse biological symptoms (hypersomnia, overeating & weight gain).

Melancholic features:

  • Depression with melancholic features referred to “involutional melancholia”.
  • Seen in old age.
  • Characterized by severe anhedonia, profound guilt feelings, early morning awakening, eight loss, agitation & high suicide risk.

Catatonic features:

  • Catatonic symptoms like stupor & negativism.

DIAGNOSTIC CRITERIA:

  • All symptoms must last for > 2 weeks.
  • SWAG (suicidality, weight loss, anhedonia and guilt feelings) – Suggestive of depression.

Exam Important

  • Depression is responsible for maximum DALYs (disability-adjusted life years) amongst all psychiatric disorders.
  • Depression is most common cause of suicide.
  • Depression is caused by neurotransmitters disturbance due to decreased levels of serotonin & norepinephrine.
  • Depression is caused by hormonal disturbance due to hypothyroidism.
  • Depression is caused by neuroanatomical disturbance due to decreased activity in dorsolateral prefrontal cortex.
  • Cognitive theory includes cognitive triad of depression which includes negative view of self (ideas of worthlessness), negative views about environment (ideas of helplessness) & negative view about future (ideas of hopelessness).
  • Symptoms of depression include insomnia, loss of interests, lack of energy, gulit feeling, poor concentration, loss of appetite & weight, suicidal thoughts, psychomotor agitation or retardation.
  • Characteristic sleep pattern in depression is early morning awakening & reduced latency of REM sleep.
  • Severe depression patients presents with psychotic symptoms (delusions & hallucinations) collectively referred as “psychotic depression”.
  • Psychotic symptoms in depression are mood congruent (content of delusion) or nihilistic delusion.
  • Melancholic features are seen in old age.
  • Depression is diagnosed only after all symptoms must last for > 2 weeks.
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Depression – Treatment

DEPRESSION – TREATMENT


DEPRESSION – TREATMENT

Treatment modalities:

  • Pharmacotherapy.
  • Psychotherapy.
  • Other somatic treatments.

1. Pharmacotherapy:

Considerations:  

  • All available antidepressants takes 3-4 weeks to exert significant therapeutic effect.
  • Usage of specific pharmacotherapy doubles chances for recover within 1 month.
  • All available antidepressants have similar profile except adverse effects.
    • Choice of drug also depends on their adverse effects.

Duration of therapy:

  • Antidepressant treatrnent should be maintained for atleast 6 months or equal to duration of previous episode, whichever is greater.
  • Prophylactic antidepressant treatment is effective in reducing number & severity of episodes.
    • Should be given to patients who have had 3 or more prior depressive episodes or in chronic major depressive disorder (> 2 years duration).

Drugs used – 

Tricyclic and tetracyclic antidepressants (TCAs):

  • 1st class of antidepressants used.

MOA: 

  • Primary action – Acts by blocking serotonin & norepinephrine transporters —> Increases neurotransmitters levels in synapses.
  • Secondary action– Antagonism of muscarinic, histaminic H1, α1 & , α2 adrenergic receptors & cardiac sodium channels bloackage. 
  • Responsible for their side effect.

Drugs included: 

  • lmipramine, desipramine, trimipramine, amitriptyline, nortriptyline, protriptyline, amoxapine, doxepin, maprotiline & clomipramine.
  • Clomipramine – Most serotinin selective drug.
  • Desipramine – Most norepinephrine selective drug.

Adverse effects: 

  • Anticholinergic side effects (constipation, urinary retention), cardiac arrhythmias, hypotension & seizures (Sodium channel bloack in heart & brain), & sedation.

Contraindications: 

  • Glaucoma, prostate hypertrophy, 

Selective serotonin reuptake inhibitors (SSRIs):

  • Most commonly prescribed antidepressants.
  • Lesser adverse effects.
  • DOC for depression, obsessive compulsivel disorder, post-traumatic stress disorder, panic disorder, generalized anxiety disorder & phobia.
  • MOA: Acts by blocking serotonin reuptake.
  • Drugs included: Fluoxetine, fluvoxamine, citalopram, escitalopram, sertraline, paroxetine, vortioxetine, & vilazodone.
  • Adverse effects: Nausea (most common) –> anxiety & diarrhoea.

Vortioxetine: 

  • Recent antidepressant.
  • MOA: Serotonin reuptake inhibitor. agonism at 5-HT1A receptor, partial agonism at 5-HT1B receptor & antagonism at 5-HT3. 5-HT1D & 5-HT7 receptors.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

  • MOA: Blockade of neuronal serotonin & norepinephrine uptake transporters.
    • Hence,“dual reuptake inhibitors”.
  • Drugs included:Venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran.

Monoamine oxidase inhibitors:

  • MOA: Inhibits monoamines enzyme (MAO-A & MAO-B) metabolism.
  • Drugs included: Non-selective MAO inhibitors – Tranylcypromine, phenelzine & isocarboxazid.

Atypical antidepressants:

Drugs included: 

  • SARI (serotonin antagonist & reuptake inhibitors): Trazodone & nefazodone.
  • NSSA (nor adrenergic and specific serotonergic antidepressant): Mirtazapin.
  • NDRI (norepinephrine-dopamine reuptake inhibitors): BupropionInhibition of norepinephrine & dopamine reuptake.
  • Serotonin reuptake enhancer: Tianeptine & amineptine – Acts by enhancing serotonin reuptake.
  • Antipsychotics: In patient with depression & psychotic symptoms.

2. Psychotherapy:

Techniques used:

  • Cognitive behavioral therapy:
    • Aims at correcting cognitive distortions (faulty ways of thinking) & faulty behaviors.
    • Most effective psychotherapeutic technique for depression.
  • Interpersonal therapy.
  • Other therapies: 
    • Behavior therapy, family therapy & psychoanalytically oriented therapy.

3.  Other somatic treatments

Electroconvulsive therapy (ECT): 

Indications: 

  • Severe depression with suicide risk.
  • Severe depression with stupor.
  • Depression with psychotic symptoms
  • Refractoriness to other treatment modalities.

Transcranial magnetic stimulation:

  • Newer modality using magnetic energy.
  • Nonconvulsive.
  • Not requires anesthesia.
  • Lesser side effects.
  • Vagal nerve stimulation.

Deep brain stimulation – 

  • Used for chronic & intractable depression.

Exam Important

  • Choice of antidepresseant drug depends on their adverse effects.
  • Antagonism of muscarinic, histaminic H1, α1 & , α2 adrenergic receptors & cardiac sodium channels bloackage by TCA’s is responsible for their side effect.
  • NDRI (norepinephrine-dopamine reuptake inhibitors) like Bupropion inhibits both norepinephrine & dopamine reuptake.
  • Serotonin reuptake enhancer like tianeptine & amineptine acts by enhancing serotonin reuptake.
  • Cognitive behavioral therapy is most effective psychotherapeutic technique for depression.
  • Electroconvulsive therapy (ECT) is therapy of choice for patient with severe depression with suicide risk & with stupor.
  • Somatic treatments methods used for treating depression includes transcranial magnetic stimulation, vagal nerve stimulation & deep brain stimulation.
  • Antidepressant drug used in nocturnal eneuresis is Imipramine.
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