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
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