depression & anxiety many faces different management jamal hafez, md professor of psychiatry the...
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DEPRESSION & ANXIETYMany Faces
Different Management
Jamal Hafez, MDProfessor of PsychiatryThe Lebanese University
Dar Al-Ajaza Al-Islamia HospitalHead of Psychiatry Department
Arab Board of Psychiatry Representative
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Depression and general practice
• France: 1 patient of 3 has significant psychiatric symptoms
• 15-20% of patients have a psychiatric disorder with or without other medical condition
• 5-10% of a GP’s patients have a depression
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Prevalence of Anxiety Disorders Lifetime % Current %
• Any anxiety disorder 24.9 17.2
• Panic disorder 3.5 2.3
• Agoraphobia without 5.3 2.8
panic disorder
• Social phobia 13.3 7.9
• Simple phobia 11.3 8.8
• Generalized anxiety 5.1 3.1 disorder
Results from National Co morbidity Survey , Kessler and al. 1994
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Under diagnosis of Depression and Anxiety
• Emphasis on somatic rather than cognitive/mood complaints
• Belief that depression and anxiety are a natural reaction to circumstance (counter transference)
• Reluctance to stigmatize patient with psychiatric diagnosis
• Nonspecific symptoms, overlap with medical illness
• Time limitations in primary care
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Anxio-Depression A new spectrum in psychiatry
• The categorical classification of mental disorders (DSM-IV , ICD-10) has limitations
• No clear boundaries between classes of disease, or even between psychopathology and normality
• Combining several types of related disorders into a large group defined as a “spectrum” has a heuristic value : it gives new insights and permits epidemiological, genetic and above all therapeutic research
• This is especially true for anxiety and depression
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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AnxietyAnxiety - - DepressionDepression
Syndromal OverlapSyndromal Overlap
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Symptoms of Depression(DISC & GAPS)
Depressed mood and/or
Interest reduction (anhedonia)plus
• Sleep disturbance• Concentration impairment, memory loss
• Energy loss, fatigue, • Guilt, feelings of worthlessness• Appetite changes, significant weight loss (or gain)
• Psychomotor retardation or agitation• Suicidal thoughts
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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What is Anxiety ?
• Cognitive (automatic ideas)
• Behavioral (avoidance)
• Physical
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Physical Symptoms of Anxiety
• Nervousness, restlessness
• Trembling
• Trouble falling or staying asleep
• Sweating
• Poor concentration
• Palpitations
• Frequent urinations
• Muscular tension
• Easily fatigued
• Light-headedness or dizziness
• Irritable mood
• Hypervigilance
• Shortness of breath
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Anxiety Disorders
DSM-IV Classification
American Psychiatric Association (1994)
GAD Panic Disorder
AgoraphobiaSocialPhobia
OCD PTSDSpecificPhobia
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GAD = generalized anxiety disorder
OCD = obsessive-compulsive disorder
PTSD = post-traumatic stress disorder
PMDD = premenstrual dysphoric disorder
DepressionDepressionPanic disorder
Panic disorder
PTSDPTSD OCDOCD
Social anxiety
disorder
Social anxiety
disorder
GADGAD
Specific phobiaSpecific phobia
PMDDPMDD
Different disorders with some common features
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Profile of the Anxious Depressed Patient
• Anxiety symptoms affect 9 out of 10 depressed patients
• Mixture of anxiety, tension and depression
• Impaired functioning compared with primary depressives
• Increased : hypochondrias is, depersonalization, chronic depression
• Reduced response to drug therapy and psychosocial intervention
• More severe and chronic illness
• Greater risk of suicide
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Panic DisorderDSM-IV Classification
• Recurrent unexpected panic attacks
• At least one of the attacks has been followed by one or more of the following for at least one month:
- persistent concern about having additional attacks
- worry about the implications of the attack
- a significant change in behaviorAmerican Psychiatric Association (1994)
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Symptomatology of Panic Attacks
• Shortness of breath smothering sensations
• Dizziness, unsteady feelings or faintness
• Palpitations tachycardia
• Trembling / shaking
• Sweating
• Choking
• Nausea / abdominal distress
• Depersonalization derealization
• Paresthesias
• Flushes / chills
• Chest pain or discomfort
• Fear of dying
• Fear of going crazy or doing something uncontrolled
Pary & Lewis (1992)
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0 5 10 15 20
Lifetime Prevalence of Anxiety Disorders
The Zurich Study
Angst (1993)
GAD
DysthymiaSimple phobia
AgoraphobiaSocial phobia
Recurrent brief anxietySporadic panic
Panic disorderOCD
Recurrent brief depressionMajor depression
Prevalence (%)
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Comparative Tolerability ofPanic Disorder Treatments
SSRIs
Benzodiazepines
Tricyclicantidepressants
Anticholinergiceffects
+
-
+++
Dependence
-
+++
-
Cardiotoxicity
-
-
++
Cognitiveimpairment
-
++
+
Withdrawalsymptoms
+
+++
+
+++ very frequent++ frequent+ infrequent
Rickels & Schweizer (1990)Klerman (1992)
Rosenberg (1993)
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• SSRI are well established as an effective treatment for all types of depression
• In panic disorder trials, SSRI improve:
- frequency of panic attacks
- anxiety associated with panic attacks
- functional ability in panic disorder patients
- depressive symptomtology
Pharmacological treatment of panic disorder
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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OBSESSIONS IN OCD
• Contamination
• Pathological doubt
• Aggressive impulse
• Somatic concerns
• Need for symmetry
• Sexual impulseRasmussen & Eisen (1992), Zetin & Kramer (1992)
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COMPULSIONS IN OCD• Washing
• Precision
• Need to ask or confess
• Checking
• Counting
• Symmetry
• HoardingRasmussen & Eisen (1992), Zetin & Kramer (1992)
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• Symptoms perceivedas excessive
• Marked distress
• Non-delusional
Differential Diagnosis of OCD
Zohar & Zohar-Kadouch (1990)
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Most Common Co-morbiditiesin OCD
Jermain & Crismon (1990), Rasmussen & Eisen (1992)
Major depressivedisorder
Panic disorder
Simple phobia
Social phobia
Alcohol & drugs abuse
Tourette’s Syndrome
Prevalence (%)0 20 40 60 80 100
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Treatment of Co-morbid OCD
OCD
+++
+++
++
+
+
+
Depression
++++
++++
++++
++++
++++
+
SSRIs
Clomipramine
Imipramine
Desipramine
MAOIs
Benzodiazepines
Goodman et al (1992)+ Little evidence; ++++ Robust evidence
Efficacy in
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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ESSENTIAL FEATURES OF SOCIAL PHOBIA
• Fear of scrutiny by other people in social situations
• Marked and persistent fear of performance situations in which embarrassment or humiliation may occur
• Avoidance of the feared situations
• Fear is disabling or causes marked distress
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SYMPTOMS OF SOCIAL PHOBIA• Physical - Tachycardia - Trembling
- Blushing
- Shortness of breath
- Sweating
- Abdominal distress
• Cognitive Automatic alarming thoughts and beliefs about social situation
• Behavioral - Freezing - Avoidance
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FEARED SITUATIONS
SOCIAL• Attending parties,
weddings etc…
• Conversing in a group
• Initiating conversation with members of opposite sex
• Speaking on telephone
• Interacting with authority figure (teacher, boss…)
• Ordering food in a restaurant
PERFORMANCE• Public speaking
• Eating in public
• Writing a cheque
• Using a keyboard
• Using public toilet
• Taking a test
• Trying on clothes in a store
• Speaking up at a meeting
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COURSE OF SOCIAL PHOBIA
Social phobia is a chronic disorder
- Average duration up to 20 years
- Only 27% of patients recover
- Around 80% of social phobic patients report at least one other psychiatric disorder
Davidson et al 1993
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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HOW CAN PHYSICIANS RECOGNIZE SOCIAL PHOBIA ?
Consider social phobia by :
• Patients who appear shy or reticent
• Substance misusers
• Depressed patients
• Patients who report anxiety attacks predominantly in social situations
STEIN , 1996
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Principes d’un bon diagnostic en psychiatrie
• Comprendre le contexte des symptômes selon le modèle bio-psycho-social
• Analyser les facteurs prédisposant, précipitant et de maintien des symptômes
• Ne pas se fier seulement à l’histoire du patient
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En cas de doute : traiter comme une depression
Rechercher de principe un trouble dépressif
Oui Non
Traitement du trouble dépressif en premier lieu
Traitement du trouble anxieux
Troubles anxieux au premier plan
Traitement d’un trouble Anxio-Dépressif
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Trouble Anxio-Dépressif Traité
Tout va bien
Traitement maintenu six mois puis arrêt
Persistance des troubles dépressifs
Dose efficace ?Durée suffisante ?
Régression partielle
Persistance de l’anxiété? Problème de personnalité?
- Tranquillisants- Relaxation- Techniques cognitives+ Soutien actif
Psychothérapie
Facteur(s) de Stress chronique?
PsychothérapieTraitement d’un trouble Anxio-Dépressif
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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CBT : Principles of Application for Anxiety Disorders
CBT targets components of anxiety, common to all the anxiety disorders :
• Physiologic activation
• Negative predictions and expectations
• Escape and avoidance behaviors
• Sense of uncontrollability
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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GOALS OF PHARMACOTHERAPY IN ANXIETY DISORDERS
• Relieve fear/anticipatory anxiety
• Reduce phobic avoidance
• Reduce autonomic/physiological distress
• Improve disability/quality of life
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Comparative Tolerability of Long Term Anxiety Treatments
SSRIs
Benzodiazepines
Tricyclicantidepressants
Anticholinergiceffects
+
-
+++
Dependence
-
+++
-
Cardiotoxicity
-
-
++
Cognitiveimpairment
-
++
+
Withdrawalsymptoms
+
+++
+
+++ very frequent++ frequent+ unfrequent
Rickels & Schweizer (1990)Klerman (1992)
Rosenberg (1993)
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DA reuptake
inhibition
Reduce depression Psychomotor activation Antiparkinsonian effects
5HT2
block
Reduce depression Reduce suicidal behavior Antipsychotic effects Hypotension Ejaculatory dysfunction Sedation
NEreuptake
inhibition
Reduce depression Anti-anxiety effects Tremors Tachycardia Erectile/ejaculatory dysfunction
5HT reuptakeinhibition
Reduce depression Anti-anxiety effects GI disturbances Sexual dysfunction
Alpha1
block
Postural hypotension Dizziness Reflex tachycardia Memory dysfunction
Anxiety
ACh block
Blurred vision Dry mouth Constipation Sinus tachycardia Urinary retention Cognitive dysfunction
H1
block
Sedation/drowsiness Hypotension Weight gain
AntidepressantAntidepressant
Richelson. In: Current Psychiatric Therapy. 1997: 286-295.
Alpha2
block
Pharmacologic effectsof antidepressants
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Ideal Pharmacological Treatment • A single agent effective against major depression and wide spectrum of anxiety symptoms
• Convenient
• Well tolerated
• Low risk of side effects, drug interactions
• Maintains long term effectiveness
May 2006 Dar Al-Ajaza Al-Islamia Hospital in Beirut
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Selective Serotonin Reuptake Inhibitors
• Documented efficacy in depression, anxiety and in the elderly
• Selective pharmacologic effect with minimal anticholinergic, adrenergic, histaminic side effects
• Once-daily dosing may improve compliance
• SSRIs with minimal inhibition of cytochrome P-450 enzymes
– Reduce risk of drug–drug interactions after discontinuation
– Have a short washout period
• Minimal cognitive impairment