Depression and Anxiety ...
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Transcript of Depression and Anxiety ...
ByBy
Soheir H. ElGhonemy Assistant Professor of Psychiatry,
MD in Psychiatry, Arab Board in Psychiatry
Member of International Society of Addiction Medicine
Depression and Anxiety
Where to go?
CNS: CNS: (Brain And Spinal (Brain And Spinal Cord)Cord)
Brain:It is a large soft mass of nerve tissue that is
contained inside a vault of bone called the cranium.
The brain monitors and regulates unconscious bodily functions like breathing and heart rate, coordinates most of voluntary movements. It is also the area of consciousness, thought and creativity.
Spinal Cord:The spinal cord is housed in a vertebral bony
vault for its own protection.
The spinal cord serves as the pathway for
nervous impulses to and from the brain. It is also
the center of reflexive actions.
Both brain and spinal cord are surrounded with
the meninges (pia, arachnoid, dura maters) and
cerebrospinal fluid.
Brain stem:It is a region continuous with the spinal cord which
is Linked to the Diencephalons and Cerebral
Cortex.
Controlling life sustaining issues i.e.; breathing,
sleep circulation and digestion.
Cerebellum:Attached to the top of the brain stem.
Coordinates sensory inputs from the inner ear and
the body muscles to provide accurate control of
position, balance and movements
Diencephalon Located just above the brain stem tucked
within the interior of the Cerebral
hemispheres.
Consists of two main components; thalamus and
hypothalamus.
The thalamus :is involved in screening out the
insignificant signals and relaying the important
sensory info to the appropriate part of the cortex.
The Hypothalamus;
Homeostasis via the regulation of
autonomic (unconscious) functions; body
temperatures, heart rate, blood pressure.
Emotional expression .
Control release of hormone from pituitary
gland
Regulation of food and water intake
Limbic system:
It is a series of nerve pathways in cooperating
structures such as hippocampus and the hippocampus and the
amygdalaamygdala, , lies within the temporal lobes. these
structures connect with the cerebral cortex,
Diencecephalon and brain stem.
Function:
Control of appetite.
Storage of memory.
Expression of mood and emotions.
Neurons:Neurons:
Neurons are the conducting cells of the
nervous system. A typical neuron consists
of a cell body, containing the nucleus and
the surrounding cytoplasm; several short
radiating processes (dendrites); and one
long process (the axon), which terminates
in twig like branches and may have
branches projecting along its course.
Synapse:Synapse:
Synapses allow nerve cells to communicate with
one another through axons and dendrites,
converting electrical impulses into chemical signals.Chemical synapses are specialized junctions through which the cells of the nervous system signal to each other and to non-neuronal cells such as those in muscles or glands. They are crucial to the biological computations that underlie perception and thought. They provide the means through which the nervous system connects to and controls the other systems of the body.
ReceptorReceptorA receptor is a protein on the cell membrane or within the cytoplasm or cell nucleus that binds to a specific molecule (a ligand); such as a neurotransmitter, hormone…..etc, and initiates the cellular response to the ligand.
Ligand-induced changes in the behavior of receptor proteins result in physiological changes that constitute the biological actions of the ligands.
Receptors exist in different types, Receptors exist in different types, dependent on their ligand and functiondependent on their ligand and function
I. Peripheral membrane proteins.
II. Transmembrane proteins, are embedded
in the lipid bilayer of cell membranes as
Dopamine receptor.
III. Intracellular proteins such as those for
steroid hormone receptors.
Neurotransmission:Neurotransmission:
Transmission Of information is carried Out by an “electrochemical Process”.
In this process the neuron Is electrically polarized & depolarized and thereby Carries “electric impulses” from the cell body to the axon terminals.
These impulses pass to the post-synaptic neuron across the synaptic cleft “a slight gap across which the signal must be transmitted”
Inverse agonist
Agonist
Partial agonist
Antagonist
Partial inverse agonist
The Agonist Spectrum
Agonist
Partial agonist
AntagonistPartial inverse
agonist
Inverse agonist
The Agonist Spectrum
NeurotransmitterNeurotransmitter
Neurotransmitter is the chemical manufactured in the neuron that aid in the transmission of information throughout the body.
1.Excitatory neurotransmitter.2.Inhibitory neurotransmitter.
Major neurotransmittersMajor neurotransmitters
1. Biogenic amines; catecholamineDopamine Excitatory Controls complex
movements, motivation, cognition, regulates emotional response.
Norepinephrine Excitatory Causes changes in attention, learning and memory, sleep and wakefulness, mood
Epinephrine Excitatory Controls fight –flight response
2. Indolamines
Serotonin Inhibitory/ Excitatory
Controls food intake, sleep, wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotion
Histamine Neuromodulators
Controls alertness, gastric secretions, cardiac stimulation, peripheral allergic responses.
3. Cholinergic
AcetylcholineExcitatory or inhibitory
Controls sleep and wakefulness cycle, memory
4. Amino acids:
Glutamate Excitatory Leads to neurotoxicity with level too high
Gamma amino butyric acid (GABA)
Inhibitory Modulates other neurotransmitters
Serotonin Pathways
Raphe Nucleus
Norepinephrine Pathways
Locus Coeruleus
hypothalamus
d
c
Nucleus accumbens
Tegmentum
bSubstantia nigra
Basal Ganglia
a
DOPAMINE PATHWAYS
The D4 receptor has the following
variants D4.2, D4.3a, D4.3b, D4.4a, D4.4b,
D4.4c, D4.4d, D4.4e, D4.5a, D4.5b, D4.6a, D4.6b,
D4.7a, D4.7b, D4.7c, D4.7d, D4.8, D4.10.
Diagnostic SystemsDiagnostic Systems
A classification system provides a common language with which all mental healthcare professionals can communicate about similar patients in various different places or countries.
Crucial for administrative and legal documentation and also for research purposes.
Diagnostic systemsDiagnostic systems
Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of Mental Disorders - 4th editionDisorders - 4th edition
Developed and printed by the APA (American
Psychiatric Association)
Only applicable to mental – psychiatric- disorders.
Multiaxial System for diagnosisMultiaxial System for diagnosis Axis I: Psychiatric disorders (clinical diagnosis) Axis II: Personality disorders + Mental retardation Axis III: Medical & Physical disorders Axis IV: Social stress Axis V: Global assessment of Function.
International Classification of Diseases International Classification of Diseases and Related Health Problems – 10th and Related Health Problems – 10th
edition edition
Developed by the WHO This system includes diagnoses of all the organ systems in the human body, not just mental disorders, therefore allowing full diagnosis of patients.Multiaxial System for diagnosisMultiaxial System for diagnosis
Axis I: Clinical Diagnosis
Axis II: Social Disabilities
Axis III: GAF
DepressionDepressionMajor depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and loss of interest or pleasure in normally enjoyable activities.
EpidemiologyEpidemiology
1. Incidence 3-7% of the
population
2. Life time prevalence 10-20%
3. Female : male is 2:1
4. Strongly associated with
medical diseases up to 30-
50%
Clinical Picture:Clinical Picture:I- Psychological symptoms:
a. Depressed mood and sadness
(diurnal variation; more severe in the
morning)
b. Loss of interest
c. Hopelessness, helplessness, self
depreciation and guilt, death wishes,
suicidal thoughts.
d. Psychotic symptoms: delusions or
hallucination (mood congruent)
II- Physiological Symptoms:II- Physiological Symptoms:
a. Decreased appetite, fatigue and loss of
energy
b. Weight loss and digestive upset
c. Sleep disturbance; insomnia, early
morning awakening, interrupted
sleep…etc
d. Loss of libido.
III- Behavioral symptoms:III- Behavioral symptoms:
a. Neglect self hygiene.
b. Social withdrawal, suicidal
attempts.
IV- Motor, cognitive symptoms:IV- Motor, cognitive symptoms:
a. Difficulty attention and
concentration.
b. Slow thinking
c. Psychomotor retardation or
agitation.
V-Impaired social and
occupational functioning.
The DSM-IV-TR recognizes five further subtypes of The DSM-IV-TR recognizes five further subtypes of
MDD, called MDD, called specifiersspecifiers, in addition to noting the , in addition to noting the
length, severity and presence of psychotic length, severity and presence of psychotic
features:features:
I-Melancholic depression:is characterized by a loss of pleasure in most or all
activities, a failure of reactivity to pleasurable stimuli, a
quality of depressed mood more pronounced than that of
grief or loss, a worsening of symptoms in the morning
hours, early morning waking, psychomotor retardation,
excessive weight loss (not to be confused with anorexia
nervosa), or excessive guilt.
II-Atypical depression:
is characterized by mood reactivity (paradoxical
anhedonia) and positivity, significant weight gain
or increased appetite (comfort eating), excessive
sleep or sleepiness (hypersomnia), a sensation of
heaviness in limbs known as leaden paralysis, and
significant social impairment as a consequence of
hypersensitivity to perceived interpersonal
rejection.
III-Catatonic depression:
is a rare and severe form of major
depression involving disturbances of
motor behavior and other symptoms. Here
the person is mute and almost stupor, and
either remains immobile or exhibits
purposeless or even bizarre movements.
IV-Postpartum depression:
(Mild mental and behavioral disorders associated
with the puerperium, not elsewhere classified in
ICD-10) refers to the intense, sustained and
sometimes disabling depression experienced by
women after giving birth. Postpartum
depression, which has incidence rate of 10–15%
among new mothers, typically sets in within
three months of labor, and lasts as long as three
months.
V-Seasonal affective disorder (SAD):
is a form of depression in which
depressive episodes come on in the
autumn or winter, and resolve in spring.
The diagnosis is made if at least two
episodes have occurred in colder months
with none at other times, over a two-year
period or longer
Course and prognosis:Course and prognosis:
1. Depression is a recurrent disorder
in 50% of cases.
2. Suicide risk is as high as 15% in
severe cases,
3. Mild cases need minimal
intervention
4. Individual episodes is generally
good
AnxietyAnxietyAnxiety is a psychological and physiological state
characterized by cognitive, somatic, emotional, and behavioral
components. These components combine to create an
unpleasant feeling that is typically associated with uneasiness,
fear, or worry.
Anxiety is a generalized mood
condition that occurs without
an identifiable triggering stimulus.
Generalized Anxiety Disorder:Generalized Anxiety Disorder:
It is the subjective sense of fear or apprehension
without objective reasoning. It is accompanied by
Autonomic manifestations and physical
discomfort.
Epidemiology:
LTP: 5-6% of the population
Age: 20-40 but can affect any age
Gender: equal in both male
and female.
Etiology:1.Genetic Factors.
2.Neurotransmitter; monoamines (NE, 5HT),
Inhibitory NT (GABA)
3.Anatomical; locus ceruleus, amygdala.
4.Psychosocial aspect; cognitive, social learning,
psychoanalytical
5.Stress diathesis model; activity of HPA axis in
biologically predisposed person when subjected to
stress
Clinical picture:Clinical picture:
A.Somatic symptoms;
a. Autonomic nervous system hyperactivity.
b. Muscle tension.
c. GIT symptoms.
d. Center nervous system.
e. Genitourinary system.
f. Cardiovascular system.
B.Psychological Symptoms.
C.Cognitive Symptoms.Deferential Diagnosis:
1. Normal anxiety; less severe, shorter
duration, for objective reason, with adaptive
response and increasing performance.
2. Medical diseases: hyperthyroidism,
cardiovascular, respiratory (COAD), head
injury, parkinsonism….etc.
3.Psychiatric Disorders: phobia, OCD,
Social anxiety, Substance use disorder,
adjustment disorder.
Course and prognosis:
GAD has chronic course, often comorbidities;
panic and depression.
Panic DisorderPanic DisorderAttacks of discrete period of intense fear
occurring over a short time develop abruptly
and reach a peak within 10 min.. It is
unexpected, recurrent attack that is not related
to specific situation.
Epidemiology:LTP: 2-3%
Age: usually young age before 30s
Sex: Female > males.
Clinical picture:Clinical picture:A.Panic attack:Attack is associated with at least 4 of the following symptoms:
a)Cardiovascular system; palpitation, pounding heart….etc
b)Respiratory system; shortness of breath, feeling of
chocking…etc
c) GIT symptoms; nausea, abdominal discomfort.
d)Center nervous system; feeing dizzy, shaking, numbness
….etc)
e)Derealization and depersonalization.
f) Autonomic overactivity.
B.Anticipatory anxiety:
In between attacks, persistent concern about
having another attack.
C.Agoraphobia:
Fearing of going to places where escape might
be difficult.
Phobic avoidance: with no treatment
patient may develop avoidance with impairment
of functions.
Obsessive Compulsive Obsessive Compulsive DisorderDisorderUndesired, irrational subjective experiences of
obsessions or compulsions.
Unwanted thought, urges or actions.
Uncontrolled (patient tries to resist).
Unacceptable.Epidemiology:LTP:2-3%
Age of onset: 15-25 yrs.
Sex: equal in both sexes.
Clinical picture:Clinical picture:
1.Obsessions: intrusive persistent unacceptable
own ideas.
2.Compulsions: repetitive voluntary act to relief
anxiety; motor or mental acts.
3.Anxiety: marked distress due to both
obsessions and compulsions.Course and Prognosis:20-30%; significant improvement
40-50%; moderate improvement.
20-30%; no improvement
Post-traumatic stress Post-traumatic stress disorderdisorder
is an anxiety disorder which results from a traumatic
experience, an extreme situation, such as combat,
rape, hostage situations, or even serious accident.
It can also result from long term (chronic) exposure to
a severe stressor, but cannot cope with continuous
combat.
a.Flashbacks,
b.Avoidant behaviors,
c.Depression.
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