Depression and Anxiety ...

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By By 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?

Transcript of Depression and Anxiety ...

Page 1: 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?

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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.

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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.

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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

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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”

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Inverse agonist

Agonist

Partial agonist

Antagonist

Partial inverse agonist

The Agonist Spectrum

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Agonist

Partial agonist

AntagonistPartial inverse

agonist

Inverse agonist

The Agonist Spectrum

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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.

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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

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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.

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3. Cholinergic

AcetylcholineExcitatory or inhibitory

Controls sleep and wakefulness cycle, memory

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4. Amino acids:

Glutamate Excitatory Leads to neurotoxicity with level too high

Gamma amino butyric acid (GABA)

Inhibitory Modulates other neurotransmitters

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Serotonin Pathways

Raphe Nucleus

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Norepinephrine Pathways

Locus Coeruleus

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hypothalamus

d

c

Nucleus accumbens

Tegmentum

bSubstantia nigra

Basal Ganglia

a

DOPAMINE PATHWAYS

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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.

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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.

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Diagnostic systemsDiagnostic systems

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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.

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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

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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.

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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%

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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)

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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.

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III- Behavioral symptoms:III- Behavioral symptoms:

a. Neglect self hygiene.

b. Social withdrawal, suicidal

attempts.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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.

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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.

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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

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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.

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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.

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3.Psychiatric Disorders: phobia, OCD,

Social anxiety, Substance use disorder,

adjustment disorder.

Course and prognosis:

GAD has chronic course, often comorbidities;

panic and depression.

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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.

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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.

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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.

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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.

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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

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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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