Symptoms of Major Depressive Disorder

Major Depressive Disorder

• Common symptoms: Sadness, hopelessness, loss of interest, changes in appetite, sleep problems, fatigue, difficulty concentrating, thoughts of death
• Diagnosis requirement: Symptoms must last for at least two weeks

Manic Episode

• Essential feature: Distinct period of abnormally elevated, expansive, or irritable mood
• Mood lability: Rapid shifts in mood, often from euphoria to irritability
• Cognitive symptoms: Grandiosity, racing thoughts, increased distractibility, poor judgment
• Grandiose delusions: Exaggerated sense of self-importance, believing they have special abilities or talents

Mania vs. Hypomania

• Mania: Symptoms are severe enough to cause significant impairment in functioning
• Hypomania: Symptoms are less severe and do not cause significant impairment

Symptoms of Mania

• Decreased need for sleep: Feeling energized and needing less sleep
• Impulsive, reckless behavior: Engaging in risky activities and behaviors without considering consequences
• Duration: Symptoms should persist for at least one week (or less if hospitalization is required)

Symptoms of Depression

• Psychomotor retardation: Slowed movements and speech, lethargy
• Grandiosity: Inflated sense of self-importance

Mood Disorders

• Cyclothymic disorder: Alternating periods of hypomanic symptoms and depressive symptoms, less severe than bipolar disorder
• Bipolar disorder: Characterized by alternating episodes of mania and depression

Hypomanic Episode

• Duration: Symptoms persist for at least four days

Diagnostic Criteria

• Hypomania vs. Mania: Hypomania is less severe and does not cause significant impairment
• Depressive episode: May include feelings of sadness, worthlessness, fatigue, loss of interest, sleep problems, and changes in appetite
• Cyclothymic disorder: Periods of hypomanic and depressive symptoms persist for at least two years (one year in children and adolescents)
• Cognitive symptoms of depression: Difficulty concentrating, negative thoughts, low self-esteem
• Pressured speech: Rapid, pressured, and difficult-to-interrupt speech

Bipolar Disorder

• Depressive episodes: Similar to major depressive disorder
• Features of manic and hypomanic episodes: Increased energy, racing thoughts, decreased need for sleep, distractibility, impulsivity, grandiosity

Anxiety Disorders

• Common symptoms: Excessive worry, fear, nervousness, restlessness, difficulty concentrating, sleep problems, muscle tension, physical symptoms
• Generalized Anxiety Disorder (GAD): Persistent, excessive worry about various aspects of life
• Physical symptoms: Nausea, palpitations, sweating
• Panic Disorder: Sudden episodes of intense fear and physical symptoms
• Agoraphobia: Fear of open or crowded spaces, often related to fear of panic attacks or inability to escape
• Depersonalization: Feeling detached from oneself or one's surroundings
• Coping mechanisms: Avoidance, reassurance seeking, worry
• Imminent death or 'going crazy': Fears associated with panic attacks
• Social Anxiety Disorder: Fear of social situations and being judged by others
• Obsessive-Compulsive Disorder (OCD): Obsessions (intrusive thoughts) and compulsions (repetitive behaviors)
• Panic attacks: Physical symptoms (dizziness, hot flashes, tingling) due to activation of the autonomic nervous system
• Separation Anxiety Disorder: Fear of separation from loved ones, often seen in children
• Cognitive symptoms: Difficulty concentrating
• PTSD (Post-Traumatic Stress Disorder): Re-experiencing trauma through intrusive thoughts, nightmares, flashbacks, and emotional distress
• Ritualistic behaviors: Repetitive behaviors aimed at reducing anxiety
• Cognitive features of anxiety: Negative thoughts, worry, catastrophic thinking
• Obsession: Intrusive, unwanted thought or image that causes distress
• Compulsion: Repetitive behavior performed to alleviate anxiety or reduce distress
• Examples of obsessions: Fear of contamination, unwanted thoughts about harming loved ones
• Examples of compulsions: Washing hands repeatedly, checking repeatedly, counting ritually
• Purpose of compulsions: Reduce anxiety or prevent perceived harm
• Intrusive thoughts or impulses: Obsessions

PTSD

• Common behavior: Avoidance of trauma-related reminders
• Key difference between OCD and PTSD: OCD involves obsessions and compulsions, while PTSD has a specific trigger (trauma)

Psychosis

• Key feature: Disconnection from reality
• Primary psychotic disorder: Schizophrenia
• Symptoms: Hallucinations (seeing or hearing things that aren't there), delusions (false beliefs), disordered thinking, disorganized speech, negative symptoms (flat affect, avolition, alogia, asociality)
• Behaviors: Odd or peculiar behavior, social withdrawal, lack of motivation
• Difficulty separating reality from fantasy: Hallucinations and delusions
• Communication difficulties: Disorganized speech, illogical responses
• Signs of psychosis: Hallucinations, delusions, disorganized behavior, lack of insight
• Possible causes of psychosis: Schizophrenia, substance abuse, brain injury, dementia
• Emotional state: Flat affect, apathy, emotional withdrawal, inappropriate emotional responses
• Common symptom of schizophrenia: Negative symptoms (flat affect, avolition, alogia, asociality)
• Secondary psychosis: Caused by underlying medical conditions, substance abuse, or other factors

Schizophrenia

• Common symptoms: Hallucinations, delusions, disorganized thinking, negative symptoms
• Positive symptoms: Hallucinations, delusions, disorganized speech
• Negative symptoms: Flat affect, avolition (lack of motivation), alogia (poverty of speech), asociality (social withdrawal)
• Hallucinations: Sensory experiences without external stimuli
• Delusions: False beliefs not amenable to logic or evidence
• Disorganized speech: Incoherent or illogical speech
• Flat affect: Blunted or absent emotional expression
• Avolition: Lack of motivation and goals, decreased activity level
• Alogia: Poverty of speech, brief and unelaborative responses
• Asociality: Social withdrawal, isolation, decreased interest in social interaction
• Substance abuse: Can cause or worsen psychotic symptoms
• Affect: Patient's outward emotional expression
• Mood: Patient's subjective emotional state

Mental Status Examination (MSE)

• Assessment: Appearance, behavior, speech, thought process, mood, affect, cognition
• Cognition: Orientation, attention, memory, judgment

Diagnoses

• Anxiety disorders: Well-kempt, pale, sweaty, agitated, wringing hands, anxious, fast speech, worried about the future, no paranoia
• Severity: Moderate to severe anxiety, depending on the degree of impairment in functioning
• Schizophrenia: Disheveled, poor hygiene, agitation, suspicion of surveillance, mumbling, blunted affect, responding to non-heard sounds
• Severity: Moderate to severe, likely requiring hospitalization
• Depression: Unkempt appearance, slumped posture, minimal eye contact, sad mood, soft speech, no interest in activities, feelings of guilt
• Severity: Moderate to severe, depending on degree of impairment in functioning

Disorders

• Generalized Anxiety Disorder (GAD): Excessive worry, restlessness, difficulty concentrating
• Schizophrenia: Disorganized thinking, hallucinations, delusions, negative symptoms
• Depression: Minimizing symptoms, attributing them to other factors

Bipolar Disorder vs. Schizophrenia

• Distinguishing feature: Mania in bipolar disorder, lack of mania in schizophrenia
• Manic episode: Elevated mood, increased energy, impulsivity
• Schizophrenia: Hallucinations, delusions, disorganized thinking
• Bipolar disorder: Elevated mood, grandiosity, racing thoughts, increased energy, decreased need for sleep
• Disconnection from reality: Schizophrenia

Other Psychiatric Concepts

• Affect: A patient's outward emotional expression
• Mood: A patient's subjective emotional state
• Grandiosity: An inflated sense of self-importance
• Pressured Speech: Rapid, pressured, and difficult-to-interrupt speech

Stroke and Mental Health

• Left-sided cortical and basal ganglia lesions are associated with higher risk of post-stroke depression and anxiety.
• Right hemisphere infarcts are linked to a higher likelihood of post-stroke psychosis.
• Post-stroke depression often peaks between 3-6 months after the stroke.
• Cognitive and emotional disorders associated with stroke may fluctuate in relation to the progression of the neurological disease.

Left Hemisphere Stroke

• Often associated with depression, anxiety, and memory/language impairments
• Impacts areas responsible for language processing, logic, and sequential thought
• Can affect speech, reading, writing, and understanding
• May lead to difficulty with tasks like following directions, planning, and problem-solving

Right Hemisphere Stroke

• Linked to perceptual issues, psychosis, and more emotional instability
• Affects spatial awareness, visual perception, and attention
• May cause difficulties with tasks like recognizing faces, understanding humor, and reading social cues
• Can result in emotional lability and impulsive actions

Frontal Lobe Stroke

• Can lead to severe personality changes, impulsive behavior, and cognitive impairments related to planning and decision-making
• Impacts the frontal lobe, crucial for executive function, personality, and behavior control
• May manifest as disinhibition, poor judgment, and difficulty focusing
• Difficulty with self-control and planning for the future

Psychogenic Nonepileptic Seizures (PNES)

• Seizure-like episodes that are not caused by abnormal brain activity, but rather by psychological factors like stress or emotional distress.
• Often misdiagnosed as epileptic seizures.
• Account for 20-30% of patients referred for intractable seizures.
• Prevalence in the general population is estimated at 2-33 cases per 100,000 people.
• Classified as a Functional Neurological Disorder in the ICD-11, requiring extensive evaluation to rule out organic causes before diagnosis.

Psychiatric Manifestations of Parkinson's Disease (PD)

• Depression is the most common psychiatric symptom associated with PD.
• Anxiety is another frequent symptom.
• Psychosis is rare in untreated individuals, but can be triggered by anti-parkinsonian medications, leading to hallucinations and delusions.
• Dementia in PD typically manifests as sub-cortical dementia with impaired executive function, personality changes, and memory impairment.
• Dopamine dysregulation syndrome, a complication of dopamine replacement therapy, can cause impulse control disorders.
• Deep brain stimulation implants for PD have been linked to cases of acute severe psychosis that resolves upon reducing the stimulation.

Psychiatric Manifestations of Head Injuries

• Head injuries can be classified as open, closed, acceleration/deceleration, focal/diffuse, each impacting the severity and type of impairment.
• Common consequences include amnesia (both anterograde and retrograde).
• Cognitive impairments can lead to personality and behavioral changes.
• Mood disorders are prevalent, with up to 50% of individuals experiencing depression after a traumatic brain injury (TBI). Mania, though less common than depression, can occur and is typically shorter in duration.
• Increased risk of suicide is associated with TBI.
• Psychosis can occur following TBI, with a higher risk for schizophrenia. Post-traumatic psychosis generally has a better prognosis than primary psychotic disorders and fewer negative symptoms. Brain damage associated with post-traumatic psychosis typically involves the frontal and temporal lobes, unlike schizophrenia, which is often associated with enlarged ventricles on brain scans.
• Increased anxiety disorders are a common consequence of TBI.

Substance Abuse Disorders and Head Injuries

• A bidirectional relationship exists between substance abuse disorders and head injuries.
• Alcohol or other drugs are directly involved in over 33% of incidents causing brain injury.
• Individuals with TBI have an increased risk of developing substance misuse or abuse disorders.

Parkinson's Disease & Psychiatric Symptoms

• Depression is the most common psychiatric symptom in Parkinson's disease.
• Dopamine replacement therapy is the medication most likely to cause hallucinations and delusions.
• Dopamine dysregulation syndrome is associated with impulse control disorders.

Psychogenic Nonepileptic Seizures (PNES)

• PNES are psychological in origin, often triggered by stress or emotional factors.
• A thorough work-up is essential to exclude any organic or neurological causes before diagnosing PNES.

Traumatic Brain Injury (TBI) - Psychiatric Manifestations

• Depression is a common psychiatric manifestation of TBI, affecting up to 50% of individuals.
• TBI can lead to post-traumatic psychosis, which generally has a better prognosis than primary psychotic disorders.
• Alcohol and drugs are involved in over 33% of incidents causing TBI.

Substance Abuse and TBI

• Substance misuse is increased following TBI.
• TBI does not decrease the risk of developing substance abuse disorders.

Neuropsychiatric Conditions

• Huntington's Disease (HD): A genetic, autosomal dominant neurodegenerative disorder characterized by a trinucleotide repeat expansion.
• Symptoms: Motor abnormalities, cognitive disturbance, and psychiatric symptoms.
• Psychiatric Symptoms: Depression is the most common psychiatric manifestation of HD, with two peaks: initial stages and during stage 2 when independence decreases. Both periods are associated with increased suicide risk.
• Other Psychiatric Conditions: Psychosis, mania, bipolar disorder, anxiety, and obsessive-compulsive disorder (OCD).
• Multiple Sclerosis (MS): An autoimmune disease affecting the white matter of the central nervous system.
• Psychiatric Symptoms: Cognitive deterioration (attention, concentration, memory, impaired decision making), mood lability, and depression.
• Depression in MS: The most prevalent psychiatric symptom, affecting 50% of individuals. Increased suicidal ideation and suicide attempts are also observed.
• Differential Diagnosis of Depression: It is essential to differentiate between primary mood disorders and drug-induced low mood. Medications like steroids, interferon, baclofen, dantrolene, and tizanidine can cause depression as a side effect.

Multidisciplinary Approaches in Neuropsychiatric Illness Management

• Delirium: Frequent in hospital settings, often referred to psychiatry, but has an organic etiology.
• Behavioral Symptoms: Aggression, disinhibition, and impulsivity are common among neurological patients, requiring careful assessment to distinguish from anxiety, agitation, and mania.
• Comprehensive Evaluation: Detailed history, physical examination, and reviewing relevant investigations are crucial to differentiate comorbid or additional psychiatric conditions (e.g., new onset anxiety, depression, or psychosis) from deterioration related to medical factors (e.g., medication changes).
• Collaboration: Effective management requires collaboration between liaison psychiatry and medical colleagues.
• Clear Referrals: Referrals should be comprehensive and include sufficient information for effective assessment.
• Proactive Problem-Solving: A proactive approach to problem-solving is essential.
• Medical Context: Understanding the medical illness and its impact on psychiatric presentations is crucial.
• Psychiatric Context: Understanding psychiatric illness and its influence on medical presentations is equally important.
• Comorbidity: Awareness of common comorbid conditions is key.
• Multidisciplinary Team (MDT): Active consideration of roles for all MDT members is essential - psychology, occupational therapy, social work, nursing, and medical specialties.

Huntington’s Disease

• Most common psychiatric symptom: Depression
• Depression peaks during the middle stages of the disease
• Independence diminishes during this stage

Multiple Sclerosis

• Common psychiatric symptoms: Cognitive deterioration, mood lability, and depression
• Baclofen, a medication for MS, may induce depression

Neuropsychiatric Illness in Hospital Settings

• Multidisciplinary approach is crucial for managing neuropsychiatric illness in a hospital setting.
• Communication and collaboration are essential between team members.
• History and physical examination should be performed to rule out organic causes if delirium is suspected.
• MDT approach benefits from the active consideration of:
  • Psychology
  • Occupational Therapy
  • Social Work
  • Medical Specialties

Managing Psychiatric and Medical Conditions

• Understanding how psychiatric illness can influence medical presentations and vice versa is vital.

Parkinson's Disease

• The primary psychiatric symptom observed in Parkinson's Disease is depression.
• Hallucinations and delusions are common psychiatric consequences of Parkinson's Disease treatment with anti-parkinsonian medication.

Head Injury (TBI)

• The most common psychiatric manifestation of head injuries is depression.
• Depression is also the most common psychiatric disorder in post-traumatic brain injury.
• Psychosis following traumatic brain injury is usually associated with enlarged ventricles on brain scans.

Psychogenic Non-Epileptic Seizures (PNES)

• Psychogenic Non-Epileptic Seizures (PNES) are seizure-like episodes due to psychological or emotional stress without abnormal brain electrical activity.
• A comprehensive work-up to rule out organic causes is key in diagnosing PNES.

Seizures

• Anxiety, depression, and paranoia are common psychiatric manifestations during the post-ictal period of seizures.

Epilepsy and Psychiatric Management

• It is important to consider psychiatric symptoms in epilepsy as part of a holistic treatment plan.
• Neurologists should work collaboratively with other healthcare professionals in a multidisciplinary team (MDT) to address both medical and psychiatric symptoms.

Neurological and Psychiatric Conditions

• It's crucial to be aware of how neurological conditions affect psychiatric symptoms and vice versa when treating patients with both neurological and psychiatric conditions.

Psychiatric Consequences of Head Injury

• Depression after TBI is common and can increase the risk of suicide.

Test your knowledge of the common symptoms associated with major depressive disorder. This quiz will help you identify which symptoms are typically recognized and which may not be commonly linked to this mental health condition.