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Lightning Round. Diferential Diagnosis of Depressive States PDF
Lightning Round. Diferential Diagnosis of Depressive States PDF
• Individuals with unipolar depression and "a little bit of mania" are more likely to have an
eventual diagnostic conversion to bipolar disorder
Benazzi F. Eur Psychiatry 2008;23:40-8; Hu J et al. Primary Care Companion CNS Disord 2014;16(2):PCC.13r01599; Sato T et al. J
Affective Disord 2004;81:103-13; Vieta E, Valenti M. J Affective Disord 2013;148:28-36.
So You Think It’s Unipolar Depression?
Clinical
History
Postpartum depressive episodes
# of hospitalizations
Antidepressant-induced hypomania
Psychotic features
Impulsivity
Aggression
Hostility
Comorbid SUD
Dervic K et al. Eur Psychiatry 2015;30(1):106-13; Angst J et al. Arch Gen Psychiatry 2011;68(8):791-9;
Musetti L et al. CNS Spectrums 2013;18(4):177-87.
Depression with Mixed Features (DMX)
Akiskal HS, Banazzi F. J Affective Disord 2005;8:245-58; Benazzi F, Akiskal HS. Psychiatry Res 2006;141:81-8; Koukopoulos A, Sani G. Acta Psychiatr
Scand 2014;129:4-16; Faedda GL et al. J Affective Disord 2015;176:18-23; Goldberg JF et al. Am J Psychiatry 2009;166:173-81; Olgiati P et al.
Depression Anxiety 2006;23:389-97; Mahli M. J Clin Psychiatry 2015;76(3):e381-2; Perugi G et al. J Clin Psychiatry 2015;76(3):e351-8; Sani G et al. J
Affective Disord 2014;164:14-8; Suppes T et al. Am J Psychiatry 2016; 173(4):400-7; Takeshima M, Oka T. Psychiatry Clin Neurosci 2015;68:109-16.
DMX and Suicidality
• Occurs in the context of brain injury, including TBI, stroke, Alzheimer's disease (AD),
amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS)
• PBA is characterized by uncontrollable, inappropriate laughing and/or crying
• Patients may experience autonomic changes, increased jaw jerk, exaggerated gag
reflex, tongue weakness, dysarthria, dysphagia, and episodic proneness to anger
• Patients with PBA often have:
• Increased risk of depression and anxiety
• Decreased quality of life
• Impaired social interaction (due to embarrassment)
• Temper
• Disinhibition
• Aggression
• Impulsivity
• Unpredictable and rapidly changing emotions
-Traumatic brain injury (symptoms of emotional dyscontrol beyond pathological laughing and crying
-Dementia (neuropsychiatric and behavioral symptoms of dementia, especially agitation, and not just pathological laughing and crying)
-Major depression, depression with mixed features, and bipolar depression, especially treatment-resistant; suicidality
Poeck
The patient’s feelings and the affective response are not closely related
The duration and severity of the episodes cannot be controlled by the patient
• Antidepressants:
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Tricyclic Antidepressants (TCAs)
• Can help reduce the frequency and severity of PBA episodes
• Typically prescribed at lower doses than for depression
• Dextromethorphan hydrobromide and quinidine sulfate (Neudexta) is the only
FDA-approved medication designed specifically to treat PBA
• Other symptoms of depression (e.g., fatigue, anhedonia, hopelessness, guilt) are not
associated with PBA
• Can be comorbid with major depressive disorder (MDD), making it difficult to diagnose
• Ictal laughing and crying can also be signs of complex partial epilepsy
• Usually accompanied by alterations in consciousness
Miller A et al. Expert Rev Neurother 2011;11(7):1077-88; Work SS et al.
Adv Ther 2011;28(7):586-601; Wortzel HS et al. CNS Drugs 2008;22(7):531-45; Pioro EP. Drugs 2011;71(9):1193-207.
Distinguishing Between PBA and Depression
PBA Depression
Brief episodes (seconds Tonic mood (last weeks
to minutes) to months)
Sudden, abrupt, no wind
down Ongoing sadness or
diminished interest
Crying
Uncontrollable
Crying not well
Exaggerated reaction or characterized
independent of mood
Emotional expression
matches patient’s mood
Distinguishing Between Bipolar Disorder and PBA
• PBA may be associated with bipolar disorders, especially with rapid cycling
or mixed mood episodes
• Laughing or crying episodes are briefer
• No disturbances between episodes
• Mood, cognition, and behavior show sustained changes in bipolar disorders
Brenner LA. Dialogues Clin Neurosci 2011;13:311-23; Diaz AP et al. J Neurotrauma 2012;29:1029-37; Rapoport MJ. CNS Drugs
2012;26(2):111-21; Rogers JM, Read CA. Brain Inj 2007;21(13-14):1321-33; Silver JM et al. Am J Psychiatry 2009;166:653-61.
Post-Traumatic Depression (PTD)
• CTE is a progressive degenerative disease that results from repetitive head trauma
• 50% of brains with NFTs also have diffuse Aβ plaques (30% of these were classic
AD neuritic plaques)