Mood Disorders: Major Depressive Disorder & Bipolar Type 1, Cyclothymia, Hypomania MDD


Distinguished future physicians welcome to
Stomp on Step 1 the only free videos series that helps you study more efficiently by focusing
on the highest yield material. I’m Brian McDaniel and I will be your guide on this
journey through Mood disorders. This is the 1st video in my playlist that covers everything
you need to know in psychiatry for the USMLE Step 1 medical board exam. In this video we
are going to review mood disorders like depression, bipolar, cyclothymia, adjustment disorder,
dysthymia and so on. Mood Disorders which are also known as Affective
Disorders, are a collection of psychiatric conditions that involve a pervasive distortion
of one’s emotional state or affect. This should not be confused with normal fluctuations
in mood. Everyone has periodic, mild changes in their affect as a result of their circumstances.
Mood disorders have more extreme changes in mood that are often unrelated to an individual’s
circumstances. However, mood disorders are characterized by periods of normal or near-normal
affect and function in between more severe mood “episodes.” Euthymia can be thought of as a neutral or
“normal” mood. This is when a person isn’t particularly happy or sad. Psychiatrically
healthy individuals spend most of the time in a euthymic state, but a “normal” patient
will have times when they feel happy or sad. In certain circumstances a healthy individual
may even have transient feelings of elation or mild depression. For example, if a person
has a really stressful work situation or they win the lottery it would be normal for them
to have a big change in their mood. However, these emotions do not lead to a loss of function
and do not persist. Changes in affect become pathologic when extreme emotions are felt,
these feelings persist and a loss of function is involved. Mood can be thought of as a continuum ranging
from extremely happy (mania with psychosis) to extremely sad (depression with psychosis
and/or suicidal ideation). Mood disorders can primarily be differentiated based on where
they lie on this continuum. And I think being able to look at that continuum
in a picture helps simplify things a lot. So here is what we are going to be working
towards during this video. I’m sure this is a bit intimidating, but don’t worry we
are going to break it down piece by piece to make it really simple. If you want a high resolution version of this
picture for your notes or because the video looks a bit fuzzy on your screen you can click
on this orange box here to be taken to my website where that is available. As you can see in the middle of our mood continuum
is euthymia or neutral mood. Then as you move in either direction you get more extreme moods.
On the right we have happy affect and to the left we have sad affect. Healthy individuals
will spend most of their time in a state of Euthymia, but they will have occasional fluctuations
from being sad to happy so this is our range of normal mood. Way out to the right we have
extremely happy mood which is mania with psychosis and way out to the left with have depression
with suicidal ideation or psychosis. The extremes of the continuum have a loss of function where
the individuals ability to function at home and at work or school are inhibited. As we
move forward we will plot each mood disorder on this same picture. Depression can involve a loss of interest
in previously pleasurable activities (AKA Anhedonia), low self-esteem, hopelessness
and fatigue. Depressed individuals may sleep way more or way less than normal, have decreased
libido, eat way more or way less than norma or have a decreased ability to concentrate.
Moderate to severe cases can cause a Loss of Function. In severe cases depression can
lead to suicidal ideation or psychosis. Psychosis is going to involve things like delusions
and hallucinations but we are going to save that topic for the next video in the series Usually when somebody says a person has depression
what they really mean is that person has Major Depressive Disorder (MDD) and they don’t
want to waste all of those extra syllables. So Major Depressive Disorder gets shortened
to Depression. But you need to recognize that depression is as emotion and MDD is a medical
diagnosis with specific criteria. You can see here in the top right corner I
give major depressive disorder and suicide a high yield rating of 9. The High Yield rating
is a scale from 0 to 10 that gives you an estimate for how important each topic is for
the step 1 exam based on a number of factors that include how often the topic appears in
retired step 1 questions. Major Depressive Disorder (MDD) is a depressive
disorder with very specific DSM criteria. These criteria involve a certain number of
symptoms over a specific time period, but these details are beyond the scope of the
USMLE Step 1 medical board exam so I will not cover them here. All you need to know
is that MDD involves having multiple moderate to severe depressive symptoms more often than
not for at least a couple weeks. We will cover treatments options for MDD in a later video. So for MDD the patient will experience everything
to the left hand side on our mood continuum. They may occasionally be euthymic, but more
often than not they are going to have moderate to severe depressive symptoms. Suicide is most often associated with Major
Depressive Disorder, but can also be the result of borderline personality disorder, psychosis,
substance abuse or other psychiatric illnesses that have a depressive component like Bipolar
Disorder or Adjustment Disorder. Suicidal Ideation is when a patient frequently has
thoughts of wanting to kill themselves, but has not actually attempted suicide……yet.
You need to ask every patient with psychiatric symptoms about suicidal ideation at every
visit. If the patient has the intent to commit suicide and a plan for doing so they need
to be hospitalized. In some cases, a patient like this might need to be Baker Acted against
their will. If a patient has thoughts of suicide, but has no plan they can be treated as an
outpatient. Recognizing depressive symptoms is pretty
easy. However, making a diagnosis of MDD is a bit tougher because there is a long differential
diagnosis for depression. In order to receive a diagnosis of MDD, the patient’s symptoms
cannot be better explained by another medical condition or substance (such as medications
or street drugs). For example, the abuse of things like alcohol or benzos can cause depressive
symptoms. Alternatively, withdrawal from stimulants like cocaine can cause depressive symptoms.
There are also numerous general medical conditions that need to be considered. Hypothyroidism
and anemia can frequently present with depressive symptoms, but they will usually give you clues
that clearly point towards those diagnoses in the question stem. For example, pale skin
or laboratory results in anemia and cold intolerance or skin changes in hypothyroidism. There are also numerous psychiatric illnesses
that can present with depressive symptoms. On the exam you have to keep an eye out for
clues that make one diagnosis more likely than another. Often the severity, duration
of symptoms and the presence or absence of acute stressors are the most important factors
to consider. So keep that in mind as we move forward Dysthmia is a milder prolonged version of
MDD. These patients have depressive symptoms for more than 2 years, but they are not severe
enough to cause a loss of function or suicidal ideation. On our continuum dysthmia would be in this
range Adjustment Disorder is sometimes referred
to as Situational Depression. It is the lack of the ability to adjust to an acute stressor
that leads to depressive symptoms that are out of proportion to the situation. These
symptoms can be severe enough to lead to a loss of function and suicide. Examples of
acute stressors would include marital problems, moving to a new city, being diagnosed with
a fatal disease or getting fired. So you can think of adjustment disorder as MDD that is
caused by a situation. This disorder usually resolve when the stressor is removed or resolves
spontaneously over a few month period as the person is able to adapt to the new situation. On our continuum adjustment disorder would
cover the same range as MDD Normal Bereavement is a normal response to
a severe stressor or personal tragedy. This most often involves grief following the loss
of a loved one. These patients have mild to moderate depressive symptoms, but can have
short periods of euthymia or even happiness during their depressive episode. In question
stems they will often describe this as having the the symptoms “wax and wane”. The patient’s
mood should slowly improve overtime and the depressive symptoms should largely resolve
over the course of a year. Normal bereavement should not be debilitating and the patient
should be able to function at home/work/school. These patients usually do not require pharmacologic
treatment. Pathologic Grief is either prolonged (lasts more than 1 year) or more extreme (loss
of function, suicide …). On our continuum Normal Bereavement would
cover this range of emotions, while pathologic bereavement would be a bit more extreme and
cover a bit more area on our table. Post-Partum Depressive Symptoms – a range
of mood disorders seen in obstetric patients after delivery. Post-Partum Blues is a common
mild form of depression that usually resolves spontaneously within a couple weeks. Post-Partum
Depression is a more severe and last more than a couple weeks. It can lead to a loss
of function and ambivalence towards the child. To prevent neglect of the child you should
make sure somebody else can help care for the child and the mother is usually treated
with SSRIs. Post-Partum Psychosis is a rare disorder where the mother may actively want
to harm the infant, because she thinks the child is evil. The mother requires inpatient
treatment and will usually be treated with antipsychotics. Mania – a period of extremely elevated mood
(AKA Euphoria) & excessive energy despite a lack of sleep. Manic individuals have rapid
speech and talk much more often than they normally do. They often they have difficulty
concentrating and are easily distracted. Mania may be accompanied by disinhibition and risky
or inappropriate behavior. It can involve irritability and delusions of grandeur (a
belief that they are famous, influential, powerful or a genius). Severe mania is sometimes
accompanied by psychosis. Manic patients have an almost complete loss of function require
hospitalization. Hypomania is a milder version of mania that usually does not require hospitalization.
Hypomania has less of an impact on function than mania, and in some cases hypomania can
actually increase productivity. Type I Bipolar Disorder=alternating periods
of mania and moderate to severe depression followed by a return to normal functioning.
However, the presence of a depressive phase is not required for a diagnosis to be made.
A single episode of mania is enough for a diagnosis even before the inevitable depressive
phase arises. This disease was formerly referred to as Manic Depression because it has alternating
periods of mania and depression. We will discuss treatment options in a later video. It is beyond the scope of the exam, but there
are actually 2 types of bipolar disease. Type I is the classic presentation which covers
the full range of moods from severe depression to severe mania. Type II can have severe depression,
but only has hypomania and not full blown mania. Cyclothymia is a related disorder that
fluctuates between mild depression and hypomania. So it would only cover this portion of our
continuum. Scizoaffective disorder is a disease that
has characteristics of bipolar disorder and schizophrenia, but I’m going to cover that
disease in my next video covering psychotic disorders because I feel like it fits a bit
better there. To see the next video in the serious that
will cover Schizophrenia and Psychotic Disorders please click this black box here But I want to take this opportunity to thank
all of you. Stomp On Step 1 has recently reached some big milestones. We now have well over
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Comments

  1. Shouldn't "Dysthmia" be spelt like "Dysthymia"? I noticed the description is spelt the same way too but you're saying it right.. maybe I'm missing something here.

  2. great material.
    Just one thing, sometimes, the subtitles cover some important information in the slides.
    Thank you so much for doing this

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