Anxiety, Depression, Anxiety, Depression, somatizationsomatization

DR.YOUSEF ABDULLAH DR.YOUSEF ABDULLAH AL TURKIAL TURKIMBBS,DPHC,ABFMMBBS,DPHC,ABFM

Consultant Family MedicineConsultant Family MedicineAssociate professorAssociate professor

King Khalid University HospitalKing Khalid University HospitalCollege of MedicineCollege of Medicine

King Saud UniversityKing Saud University

ScenarioScenario

• Ibrahim 40 years old nurse presented to Ibrahim 40 years old nurse presented to primary care clinic complaining of primary care clinic complaining of depressed mood most of the day, loss of depressed mood most of the day, loss of interest, insomnia, decreased appetite, interest, insomnia, decreased appetite, hopelessness, and pessimistic and quilty hopelessness, and pessimistic and quilty thought.thought.

• HOW YOU WILL PROCEED DURING THIS HOW YOU WILL PROCEED DURING THIS CONSULTATION?CONSULTATION?

Epidemiology of DepressionEpidemiology of Depression

• Saudi ArabiaSaudi Arabia

• SexSex

• AgeAge

• Marital statusMarital status

Etiology of DepressionEtiology of Depression

• Psych social stress commonestPsych social stress commonest

- stress at home- stress at home

- stress at school- stress at school

- stress at work- stress at work

- marital problem- marital problem

- financial problem- financial problem

• Biological theory: serotonin, Biological theory: serotonin, norepinephrin, and dopaminenorepinephrin, and dopamine

ContinueContinue

• Genetic theoryGenetic theory

• Drug and alcohol abusedDrug and alcohol abused

• UnknownUnknown

Classification of depressionClassification of depression

• Unioplar : only depressionUnioplar : only depression

• Bipolar : depression / maniaBipolar : depression / mania

• Major/ minor Major/ minor

• Old: endogenous/ reactiveOld: endogenous/ reactive

neurotic/ psychoticneurotic/ psychotic

Clinical featureClinical feature

• Not every sadness mean depressionNot every sadness mean depression

• Criteria for major depressive episodeCriteria for major depressive episode

• One of the following: One of the following:

• 1- depressed mood :all the days1- depressed mood :all the days

• 2 loss of interest or pleasure : all the days 2 loss of interest or pleasure : all the days

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• Five( or more) of the following during Five( or more) of the following during the same 2 weeks:the same 2 weeks:

• 1- depressed mood most of the day1- depressed mood most of the day

• 2- Marked diminished interest or 2- Marked diminished interest or pleasure in al most all activitiespleasure in al most all activities

• 3- decrease appetite/ or increased3- decrease appetite/ or increased

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• 4- insomnia or hypersomnia4- insomnia or hypersomnia

• 5- psych motor retardation or agitation5- psych motor retardation or agitation

• 6- fatique every day6- fatique every day

• 7- feeling of worthlessness/ pessimistic7- feeling of worthlessness/ pessimistic

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• 8- recurrent thought of death8- recurrent thought of death

• 9- decreased ability to think and 9- decreased ability to think and concentrateconcentrate

• SUICIDE ???? Severe depressionSUICIDE ???? Severe depression

Differential diagnosisDifferential diagnosis

• Normal sadnessNormal sadness

• Hypo thyroids Hypo thyroids

• AnxietyAnxiety

• drugs side effectsdrugs side effects

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• DementiaDementia

• Parkinson's diseaseParkinson's disease

• Adrenal dysfunctionAdrenal dysfunction

managementmanagement

• Psych social approach: support at: Psych social approach: support at: home, work, financial, relationshiphome, work, financial, relationship

• Psych therapy: help patient to decrease Psych therapy: help patient to decrease stress, and cope with stressstress, and cope with stress

• 1- cognitive psychotherapy : +ve 1- cognitive psychotherapy : +ve thinkingthinking

• 2- ventilation psychotherapy2- ventilation psychotherapy• 3- family suport3- family suport

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• Pharmacological therapy:Pharmacological therapy:

• Tricyclic antidepressantTricyclic antidepressant

• SSRI: selective serotonin re-uptake SSRI: selective serotonin re-uptake inhibitorinhibitor

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• effect of drug &Duration of treatmenteffect of drug &Duration of treatment

• Compliance to medication: S/ECompliance to medication: S/E

• When to refer to psychiatrist?When to refer to psychiatrist?

PrognosisPrognosis

• Good if treated earlyGood if treated early

• need psych Social supportneed psych Social support

ScenarioScenario

• Nasser 28 years old Chief manger presented Nasser 28 years old Chief manger presented to primary care clinic complaining of to primary care clinic complaining of excessive worry and sense of impending excessive worry and sense of impending disaster without evidence of appropriate real disaster without evidence of appropriate real danger, started 9 month ago. He had history danger, started 9 month ago. He had history of muscular ache, abdominal discomfort, dry of muscular ache, abdominal discomfort, dry mouth, palpitation, frequent attack of short mouth, palpitation, frequent attack of short ness of breath, cold extremities and wet ness of breath, cold extremities and wet palm during the last 7 month.palm during the last 7 month.

• HOW YOU WILL APPROACH NASSER?HOW YOU WILL APPROACH NASSER?

Epidemiology of AnxietyEpidemiology of Anxiety

• Saudi ArabiaSaudi Arabia

• AgeAge

• SexSex

• Marital statusMarital status

EtiologyEtiology

• Psych social stressPsych social stress

• Relationship problemRelationship problem

• Financial problemFinancial problem

• Anxious PersonalityAnxious Personality

• Physical illness Physical illness

• Genetic theoryGenetic theory

Clinical featureClinical feature

• Normal physiological anxietyNormal physiological anxiety

• Generalized anxiety disorder:Generalized anxiety disorder:

• Continuous and chronic state of Continuous and chronic state of excessive worry or apprehensive for excessive worry or apprehensive for > 6 months> 6 months

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• Psychological: fear or apprehension, Psychological: fear or apprehension, restless ness, initial insomnia, poor restless ness, initial insomnia, poor concentration.concentration.

• Physical: muscular ache, headache, Physical: muscular ache, headache, bone ache, dry mouth, palpitation, bone ache, dry mouth, palpitation, sweating, wet palms.sweating, wet palms.

Differential diagnosisDifferential diagnosis

• Physiological anxiety: short durationPhysiological anxiety: short duration

• Hyper thyroidHyper thyroid

• drug or alcohol withdrawaldrug or alcohol withdrawal

• PhechromocytomaPhechromocytoma

• HypoglycemiaHypoglycemia

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• Panic attackPanic attack

• phobiaphobia

managementmanagement

• RelaxationRelaxation

• Supportive counselingSupportive counseling

• PsychotherapyPsychotherapy

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• Pharmacological: Pharmacological:

• B-blocker: physical symptomB-blocker: physical symptom

• Benzodiazepine :Benzodiazepine : for short period less for short period less than1- 2 week WHY?than1- 2 week WHY?

• Drug dependenceDrug dependence• Alternative: small dose of tricyclic anti Alternative: small dose of tricyclic anti

depressantdepressant

prognosisprognosis

• Good prognosis Good prognosis

• If diagnosed and treated early no If diagnosed and treated early no recurrent in majorityrecurrent in majority

scenarioscenario

• Khalid 35 years old present to primary care clinic Khalid 35 years old present to primary care clinic complaing of dizziness, backache and indigestion.complaing of dizziness, backache and indigestion.

• His file show: for the last 7 month, he presented with the His file show: for the last 7 month, he presented with the following: abdominal pain, nausea, intolerance to 15 following: abdominal pain, nausea, intolerance to 15 different foods, backache, shortness of breath at rest, chest different foods, backache, shortness of breath at rest, chest pain, dizziness, difficulty swallowing, palpitation.pain, dizziness, difficulty swallowing, palpitation.

InvestigationInvestigation: Blood test 5 times : Blood test 5 times chest x-ray 3 times, ECG ( 6 times), ultrasound abdomin (2 chest x-ray 3 times, ECG ( 6 times), ultrasound abdomin (2

times), CT scan abdomin( 2 times), upper Gi endoscopy (2 times), CT scan abdomin( 2 times), upper Gi endoscopy (2 times), colonoscopy oncetimes), colonoscopy once

ALL investigations were NORMALALL investigations were NORMAL

HOW YOU WILL MANAGE KHALID?HOW YOU WILL MANAGE KHALID?

What is somatization?What is somatization?

• One of the commonest mode of presentation One of the commonest mode of presentation in general practicein general practice

• Expression of psychological problems in Expression of psychological problems in physical complaintsphysical complaints

• Multiple, recurrent, change physical Multiple, recurrent, change physical symptomssymptoms

• ? hypochondriasis? hypochondriasis

Clinical featuresClinical features

• Could be presented by any physical complaintCould be presented by any physical complaint

• Absence of organic pathologyAbsence of organic pathology

• Seen by different doctors and hospitalsSeen by different doctors and hospitals

• Depression and anxiety underlying Depression and anxiety underlying somatizationsomatization

mangementmangement

• Explain to the patient and family Explain to the patient and family relationship between psych and somaticrelationship between psych and somatic

• Empathic attitudeEmpathic attitude

• Avoid unnecessary investigationAvoid unnecessary investigation

• Treat underlying depression and anxietyTreat underlying depression and anxiety

prognosisprognosis

• Somatization likely to be chronic and Somatization likely to be chronic and difficult to treatdifficult to treat

• If treat underlying depression and If treat underlying depression and anxiety early , patient will respondanxiety early , patient will respond

conclusionconclusion

• Anxiety, depression, and Anxiety, depression, and somatization are common psychiatric somatization are common psychiatric illness at primary care levelillness at primary care level

• Good consultation and Good consultation and communication skills with patients communication skills with patients will help family physician to diagnose will help family physician to diagnose psychiatric illness early.psychiatric illness early.

WITH MY BEST REGARDSWITH MY BEST REGARDS