Mood Disorders – Anxiety Disorders MRCPsych Paper 3

Dr Nicoletta P. LekkaConsultant in General Adult Psychiatry

Sheffield, 10th December 2013

Outline of Lecture

• Introduction• Depressive

Disorders• Bipolar Affective

Disorders• Anxiety Disorders• MCQs - EMIs

ICD-10 Classifications

• Manic Episode• Bipolar Affective Disorder• Depressive Episode• Recurrent Depressive Disorder• Persistent Mood Disorders

(Dysthymia, Cyclothymia)• Other Mood Disorders (e.g. Mixed

Affective Episode, Recurrent Brief Depressive Disorder)

Other Possible Diagnoses with Mood features (I)

• Organic Mood Disorders• Psychoactive Substance Use

Disorders Psychotic disorders (predominantly depressive); Residual Affective Disorders• Schizoaffective Disorders• Mixed Anxiety-Depressive disorders

Other Possible Diagnoses with Mood features (II)

• Reaction to Stress & Adjustment Disorders• Somatoform Disorders• Other neurotic disorders• Anorexia Nervosa• Non-organic insomnia

DSM-IV Classifications

•Dysthymic disorder•Major depressive disorder

▫Major depressive disorder, recurrent

▫Major depressive disorder, single episode

•Depressive disorder NOS

DSM-IV Classifications

•Bipolar disorder NOS•Bipolar I disorder•Bipolar II disorder•Cyclothymic disorder•Mood disorder due to... [indicate the

general medical condition]•Mood disorder NOS

MCQ 1

• The prevalence of depressive disorder in women compared to men is: • equal• 2-fold greater • 3-fold greater • 5-fold greater • 7-fold greater

Epidemiology (Incidence-Prevalence)

• Major depressive disorder: • a common disorder, with a lifetime

prevalence of about 15%, perhaps as high as 25% for women. • Incidence of major depressive

disorder: • 10% in primary care patients and

15% in medical inpatients.

Epidemiology (Gender)

• An almost universal observation, independent of country or culture: • the 2-fold greater prevalence of major

depressive disorder in women than in men. • Reasons for the difference: hormonal

differences, the effects of childbirth, differing psychosocial stressors for women and for men, and behavioural models of learned helplessness.

Epidemiology (Age)

• Onset of bipolar I disorder: earlier than that of major depressive disorder.

• Mean age of onset: 40 years. • 50 percent of all patients have an onset

between the ages of 20 and 50. • Major depressive disorder can also begin

in childhood or in old age. • The incidence of major depressive disorder

may be increasing among people < 20 years old.

• This may be related to the increased use of alcohol and drugs of abuse in this age group.

Epidemiology

• Ethnic group: No evidence after adjusted social class difference• No correlation between socioeconomic

status and major depressive disorder. • Marital Status: • Highest in divorced/cohabiting (x 2-3 times)• Low rates in never married• Lowest: married & never divorced

• Geographic Area• Urban < Rural

MCQ 2

In depressive disorder we see: 1. Brief episodes of anxiety 2. Rituals 3. Obsessions 4. Suicide 5. Higher dizygotic twin concordance

rather than monozygotic

MCQ 3

Something that is diagnostic of depressive disorder is: 1. Attempts to avoid real or imagined

abandonment2. Anxiety3. Loss of interest & enjoyment4. Suicide 5. Self-harm

Clinical Features

Clinical Features (I)

Core symptoms:• Depressed Mood• Loss of interest & enjoyment

(anhedonia)• Reduced energy

• Mild to moderate episodes: only 2 out of 3 core symptoms (“depressed mood” is not absolutely necessary)

Clinical Features (II)

Somatic syndrome: (any 4)• Diurnal Mood variation• Lack of emotional response to events/

activities• Anhedonia• Psychomotor retardation/ agitation• Early morning wakening• Loss of appetite• Weight loss• Loss of libido

Clinical Features (III)

Feelings of •Hopelessness •Pessimism•Guilt •Worthlessness•Helplessness

Clinical Features (IV)

• Loss of functioning is an important diagnostic criterion• Psychotic symptoms:• Nihilistic delusions, delusions of guilt,

poverty, hypochondriasis; Hallucinations: olfactory (unpleasant smell), auditory (derogatory)

• Atypical features: • increased sleep, appetite & weight

• Other symptoms: anxiety, O-C features

MCQ 4

In melancholia, which of the following is true:1. Feelings of paranoia are directed

inward at the self2. It does not result from loss3. It protects the ego against despair4. Feelings of anger/aggression are

directed inward at the self 5. There is no loss of ambivalent object

Rating Scales

• Self-rated:• Beck Depression Inventory (BDI)• Zung Depression Scale

• Observer rated:• Hamilton Depression Rating Scale (HDRS)• Montgomery-Asberg Depression Rating

Scale (MADRS): good to measure changes in depressed patients

Aetiology

Aetiology - Genetics

• 1st degree relatives of depressed probands, compared to 1st degree relatives of controls:• >1.5-2.5 times to have bipolar disorder • >2-3 times to have depression

• Twin studies:• Monozygotic concordance ratio: 50%• Dizygotic concordance ratio: 10-25%

Aetiology - Genetics

• Adoption studies: support genetic theories (the biological children of affected parents remain at risk of a mood disorder, even if they are reared in non-affected families)

Aetiology – Early environment

• Parental style: Inadequate parenting appears to be more significant (lack of care, overprotection/ high level of control)• Parental Loss: parental discord seems

to be more important factor• Childhood sexual abuse in women

Aetiology – Life events

• Stressful life events more often precede first, than subsequent episodes• The stress accompanying the first

episode results in long-lasting changes in the brain’s biology

Aetiology – Life events

• Loss of spouse• Loss of parent before age

11• Unemployment

• Threatening & undesirable life events

• Low self-esteem

Personality factorsObsessive-compulsive,

Histrionic, Borderline PD, perhaps at greater risk than Antisocial or Paranoid PD, who use externalising defence mechanisms.

Psychological Theories

• Psychoanalytic theory:• Freud: melancholia results from loss.

Feelings of anger/aggression are directed inward at the self

• Cognitive/Behavioural theory:• Wolpe: depression conditioned by

repeated losses in the past• Seligman: “learned helplessness”,

experience of uncontrollable events

Psychological Theories (II)

• Specific cognitive distortions present in persons prone to depression– Maladaptive Schemata (ways of

organising and interpreting experiences)

– Beck: Negative Cognitive Triad: Beliefs about oneself (negative self-perception), the world (hostile and demanding), the future (expectation of suffering and failure)

Biochemical Theories

• Monoamine Hypothesis: Dysregulations of biogenic amines• Serotonin (5HT)• Noradrenaline (NA)

• Clinical effectiveness of antidepressants• Some patients with suicidal tendencies

have low CSF concentrations of serotonin metabolites & low concentration of serotonin uptake sites on platelets

Neuroendocrine Theories

• Various neuroendocrine dysregulations, more likely reflect a fundamental brain disorder– Increased 24hr cortisol secretion in 50%

moderate/severe depressive cases; also loss of circardian rhythm

– Dexamethasone non-suppression– Blunted ACTH response to CRH– 1/3 have blunted TSH response to TRH

Neuroimaging

• Structural: • Enlarged ventricles on CT but

inconsistent• Subcortical white matter

hyperintensities in MRI in elderly depressive

• Functional:• Reduced activation on prefrontal

cortex, cingulate cortex and some region of basal ganglia

Neuroanatomical Considerations

• People with neurological disorders of the basal ganglia and the limbic system are likely to show depressive symptoms

• Depressed patients' alterations in sleep, appetite, and sexual behaviour and biological changes in endocrine, immunological, and chronobiological measures suggest dysfunction of the hypothalamus

• Depressed patients' stooped posture, motor slowness, and minor cognitive impairment are similar to the signs of disorders of the basal ganglia, such as Parkinson's disease

MCQ 5

Which of the following is least commonly associated with poor outcome of depression? Options: 1. Coexisting dysthymia 2. Alcohol/Substance abuse3. Anxiety disorder symptoms4. Absence of psychotic symptoms5. History of >1 previous episodes

Differential diagnoses to consider• Mild/ Moderate• Normal sadness/

bereavement• Anxiety disorders,

phobias (e.g. agoraphobia)

• OCD• Dysthymia• Personality Disorder

• Moderate/ Severe• Schizophrenia• Delusional disorders• Dementia• Organic depressive

disorders

Organic Depressive Disorders• Endocrine: cortisol, thyroid, parathyroid• Infections: syphilis, HIV• Nutritional: B12, folate deficiency• CNS: CVA, Parkinson’s disease, MS,

meningioma, cerebral lupus• Malignancy: non-metastatic manifestation

(e.g. pancreatic)• Drugs: anti-hypertensives; steroids; L-

DOPA• Withdrawal of illicit drugs:

amphetamines, benzodiazepines, cocaine

Other presentationsAtypical depression• Sometimes called masked depression• Usual mood symptoms are not

prominentPresentations include:• Physical symptoms• Hypochondriasis• Histrionic features• Hypersomnia • Overeating• Behavioural changes

Course & Outcome

• 10% develop bipolar disorder• Risk factors for bipolar:• Psychomotor retardation• Family history of affective disorders• Family history of mania• Hypomania during drug therapy• Psychotic symptoms• Hypersomnia

Course & Outcome (II)

• Risk of relapse lower than in bipolar but still high • Over a 20-year period: 5-6 episodes• As the disorder progresses: more

frequent episodes that last longer• Recurrence after hospitalization: • 25% after 6 months• 30-50% in 2 years• 50-75% in 5 years

Course & Outcome (III)• Untreated episodes:

6-13 months• Treated: 3 months

• Good prognostic factors:• Mild episodes• Absence of

psychotic symptoms• Short hospital stay

Course & Outcome (IV)

• Poor outcome associated with:• Coexisting dysthymia• Alcohol/Substance abuse• Anxiety disorder symptoms• History of >1 previous episodes

• Suicide rates around 9-15%

Long-term Management of Depression• It is important for both clinician and patient to

understand rates of response, relapse, and remission

• Given that the majority of patients do not reach remission, augmentation strategies, including both medication and psychotherapy, are often used to maximise response

• Treating residual symptoms to prevent relapse is vital for the long-term outcome in the care of the depressed patient

Residual SymptomsAs clinicians, the goal is to minimize residual side

effects which can lead a patient to relapse.• Common residual symptoms may include anxiety,

somatic symptoms, sleep disturbances, fatigue, apathy, and/or cognitive and executive dysfunction.

• For many patients it is often difficult to assess whether side effects are residual or part of antidepressant treatment.

• 10% to 20% of patients treated with antidepressants experience anxiety or agitation.

Long-term Management of Depression For patients who do not achieve remission

with an antidepressant: importance of •evaluating that the appropriate diagnosis

was made•assessing whether the patient suffers

from a comorbid condition, or •whether there are additional life stressors

present that are hindering response

Choice of Medications•There are a number of medications

commonly used in the treatment of depression including SSRIs and TCAs

•Clinicians tend to initially choose medications based on specific symptoms, co-morbid conditions, or the side-effect profiles of the medications

•Medications tend to be similar within classes and data do not support that newer agents are more efficacious

Patient Education• Patients should be encouraged to remain on a

medication for at least 4 weeks and, when possible, for 6-8 weeks, provided that side effects can be tolerated

• Patient education is important -- information on side effects, time frame for medication effect, and (when possible) material to take home

• If patients have support available to them when they go through temporary side effects and they feel that they have developed a good relationship with their doctors, they are more likely to remain on medications

Augmentation Strategies• Many patients fail to respond to monotherapy

and, in an effort to optimise response, augmentation and adjunctive strategies are being used

• Remission is not possible for a significant number of patients. Given the substantial placebo effect in research surrounding clinical trials in psychiatry, current research does not provide a tremendous amount of guidance

• Presently, the best reviewed augmentation therapies include lithium and thyroid hormones

Augmentation Strategies• Lithium is associated with burdensome side

effects, requires monitoring, and liability issues can be a concern.

• Thyroid medication has been reported to be useful, but trials are mostly small and follow-up testing is needed.

• The use of atypical antipsychotics was considered as an augmentation strategy in mood disorders. Original studies showed an early benefit, but tracked over time in large multicentre double-blind trials, they did not separate from placebo.

MCQ 6

A woman comes to your out-patient clinic. She says she lost her husband 1 month ago and reports suicidal ideation & that she is feeling depressed. You decide:

1. To start no treatment but review her in three months.

2. Start an antipsychotic and review in 3 months. 3. Start an antidepressant and review in 3 months. 4. To discharge her to her GP as this is normal

bereavement.5. To start no treatment but review her in three

weeks.

MCQ 7

A man comes to your clinic nine months after the death of his mother. You find features of a moderate depressive illness. He occasionally hears her voice calling him. You decide to: A. Do nothing and reassure him it will all

go away. B. Start an antidepressant and follow him

up. C. Start an antipsychotic and follow him up.

MCQ 8

• Differences of hypomania and mania:1. Sustained for 1 week / requires hospital

admission2. Flight of ideas/ thought racing3. Psychotic features4. Inflated self-esteem/ grandiosity5. Loss of normal social inhibitions

Bipolar Affective Disorder – terms to clarify

• Bipolar: at least 2 episodes of mood disturbance, with one either hypomania, mania or mixed affective.• Usually characterised by complete

recovery between episodes.• Pure mania (i.e. without any depressive

episodes) is uncommon.

Bipolar I, II

• Bipolar I• Depressive & manic

episodes• Bipolar II• Depressive &

hypomanic episodes (may be precipitated by antidepressants)

Epidemiology

• Prevalence: lifetime – Bipolar I disorder: less common than major depressive disorder, with a lifetime prevalence of about 1%, similar to the figure for schizophrenia• Mean age of onset : 30• 90% develop disorder before age of 50• Social class: inconsistent findings but

ECA study showed no differential prevalence with occupation, income or education• Ethnic group: no association

Epidemiology (II)

• Male: Female = 1:1• Manic episodes are more common in

men, and depressive episodes are more common in women. • When manic episodes occur in

women, they are more likely than men to present a mixed picture (e.g. mania and depression). • Women: higher rate of being rapid

cyclers, (having four or more manic episodes in a 1 year period).

Epidemiology (III)

• More common in urban areas• Marital status: • ECA study showed lower rates amongst

married than divorced or never married• Multiple divorced individuals showed

increased rate (? Effect of illness – higher divorce rate for BAD)

Clinical features

• Hypomania: • Elevated / irritable mood for at least 4

consecutive days• Increased activity or physical restlessness• Increased talkativeness• Difficult to concentrate or distractible• Decreased need for sleep• Increased sexual energy• Mild overspending or other reckless or

irresponsible behaviour• Increased sociability or overfamiliarity

Clinical features (II)

• Mania: Differences from hypomania• Expansive mood• Sustained for 1 week / required hospital

admission• Flight of ideas/ thought racing• Loss of normal social inhibitions• Inflated self-esteem/ grandiosity• Psychotic features

• Differences between hypomania & mania are vague except with psychotic features mania

Aetiology - genetics

• 1st degree relatives of bipolar probands, compared to 1st degree relatives of controls:• >8-18 times to have bipolar disorder • >2-10 times to have depression

• Twin studies:• Monozygotic concordance ratio: 33-

90%• Dizygotic concordance ratio: 5-25%

Aetiology: Psychosocial

• Life events:• Increased rate of life events in the

month before• Increased relapse rate in:• Post-partum period• Disturbances in sleep-wake schedule

(air travel/ shift work)• High expressed emotion at home

Aetiology: Psychosocial (II)

• Psychoanalytic:• Freud: Loss of ambivalent object (same

as depression)• Winnicott: “Manic defence” against

depression (omnipotent control, triumph, contempt) – to protect ego against despair

Secondary Mania

• CNS: CVA (esp. Rt-side cerebral lesion), head injury, tumour, MS, dementia• Endocrine: Thyrotoxicosis, Cushing’s

disease• Medication: bromocriptine, steroid,

thyroid hormone, isoniazid, L-DOPA• Substance misuse: amphetamine,

cocaine, cannabis

MCQ 9Which of the following is true:

A. Depressive episodes tend to last longer than manic (median 6 months)

B. Manic episodes last from 2 to 3 weeksC. More than 80% of manic episodes last

more than 1 month with treatmentD. More than 90% of manic episodes last

more than 1 month with treatmentE. Depressive episodes tend to last longer

than manic (median 12 months)

Course & Outcome

• Manic episodes usually begin abruptly and last from 2 weeks to 5 months (median 3-4 months)• More than 50% of episodes last less

than 1 month with treatment• Depressive episodes tend to last

longer (median 6 months)

Course & Outcome (II)

• Wide variation of the outcome & course and no predictive factors established.• Average number of episodes 6.5 (more

episodes compared to unipolar depression)• Inter-episode interval = 6-9 months

(interval tends to reduce over the first 5 episodes)• Frequency of episodes seems to increase

in the first 10 years, before ceilingceiling

Course & Outcome (III)

• Overall trend is shorter remissions, longer depressive episodes with time• Suicide rate probably similar to

unipolar depression (~15%)• Higher rate in Bipolar Patients:• Divorce• Alcohol and substance misuse

(particularly for bipolar II)

Prognosis

• Poor : Premorbid poor occupational status, alcohol dependence, psychotic features, depressive features, interepisode depressive features, and male gender• Good : Short duration of manic

episodes, advanced age of onset, few suicidal thoughts, few coexisting psychiatric or medical problems

Mania: Acute Phase Therapy - Prophylaxis

•Despite the increasing array of antimanic therapies, relatively few patients remit rapidly and fully with a single medication and even fewer will recover and remain well for years thereafter.

•As a result, most manic patients now receive complex medication regimens, including an atypical antipsychotic in addition to a conventional mood stabiliser such as lithium or valproate, at the least.

Mania: Acute Phase Therapy - Prophylaxis

Although the efficacy of many such combinations is unquestioned on clinical grounds, such complex treatment regimens are more costly and associated with a greater side effect burden, a higher likelihood of drug-drug interactions, and poorer adherence

MCQ 10

A 17 year old girl has features of a moderate depressive illness. The correct treatment is:

A. CBT B. SSRI C. CBT and SSRI D. TCAE. ECT

MCQ 11

What would you do for a patient with depression and no improvement after two months on 50 mg of Sertraline: A. Increase the Sertraline B. Change to a different SSRI C. Add an antipsychotic D. Switch to Venlafaxine E. Add Sodium Valproate

Rapid Cycling

• First coined by Dunner & Fieve (1974)

• 4 or more mood episodes per year (each episode demarcated by a switch to an episode of opposite polarity or by a period of remission)

Rapid Cycling (II)• Characteristics:• More common in women• Tends to develop late in the course of illness• Worse prognosis • Lithium resistance (80%)

• Risk factors:• Alcohol & Substance Misuse• Use of antidepressants (esp. induced mania)• Hypothyroidism • Other Medical conditions: CVA, Head injury,

MS

Mixed Affective State

• During transition from one pole to the other: mood, cognition & behaviour may vary independently, producing “mixed” states (Kraepelin)• Examples: manic stupor, depression with

flight of ideas

Mixed Affective State (II)• More likely to have a

history of substance misuse

• Transient “depressed” mood is common in manic patient ≠ Mixed Affective State: both manic & depressive symptoms should be prominent

Cyclothymia

• Features:– At least 2-year of mood instability with both

depression and hypomania– None of the manifestations fulfil a manic or

depressive (moderate/severe) episode during these 2-year period – however, can have mood episode before/after

Cyclothymia (II)• Lifetime prevalence about 1% in general

population• Onset: 15-25 years• Common in relatives of patients with

mood disorders• 33% will develop bipolar disorder• Association: • Substance abuse• Borderline personality disorder

Dysthymia

• Features:– Chronic, low grade depression which is

rarely severe enough to fulfil criteria for mild depressive episode

– For at least 2 years– No hypomania– May superimpose with a major depressive

episode – “double depression”

Dysthymia (II)• Lifetime prevalence in

general population = 3%

• More common in women, unemployed

• Usually insidious onset before age 25

• Also associated with alcohol & substance misuse

MCQ 12Which of the following best describes problems

potentially encountered during treatment with SSRI medications?

A.Dependence on SSRIs is widely accepted as a complication of their use

B.Risk of seizures should strongly dissuade clinicians from prescribing SSRIs in people with epilepsy

C.Sexual side effects are less commonly encountered than with mirtazapine

D.Nausea is the single most commonly encountered side effect on initiation

E.Sedation is more common than is the case with imipramine

Extended Matching Item (EMI)

• Options: Atypical antipsychotics – Benzodiazepines – Mirtazapine – Lithium – Venlafaxine – SSRIs – CBT - ECT - None of the above

Each option might be used once, more than once, or not at all.1. A 37-year-old woman with a history of relapse of

depression and poor or limited response to pharmacological interventions

2. A 54-year old man with depression who has failed two adequate trials of alternative SSRIs.

3. A 45-year old woman who has responded to a pharmacological intervention but is unwilling to continue with that intervention and is assessed as being at significant risk of relapse of depression.

ICD-10 Classifications

•Phobic Anxiety Disorders AgoraphobiaSocial Phobias Specific (isolated) phobias

•Panic Disorder•Generalized Anxiety Disorder•Obsessive-Compulsive Disorder

ICD-10 Classifications

•Acute Stress Reaction•Post-traumatic Stress Disorder•Adjustment Disorder

DSM-IV Classifications

•Generalized Anxiety Disorder•Panic Disorder

▫With Agoraphobia▫Without Agoraphobia

•Agoraphobia without history of Panic Disorder

DSM-IV Classifications•Specific Phobia•Social Phobia•Obsessive-Compulsive Disorder•Post-traumatic Stress Disorder•Acute Stress Disorder•Anxiety Disorder due to... [indicate

the general medical condition]•Anxiety disorder NOS

Anxiety

•A psychological and physiological state characterised by cognitive, somatic, emotional, and behavioural components.

•These components combine to create an unpleasant feeling that is typically associated with uneasiness, fear, or worry.

Epidemiology

•One in four persons meets the diagnostic criteria for an Anxiety Disorder

•12-month prevalence rate: 17.7%•Women: 30.5% lifetime prevalence•Men: 19.2% lifetime prevalence•Prevalence decreases with higher

socioeconomic status

Generalized Anxiety Disorder (GAD)

•Excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry.

•Interferes with daily functioning, as individuals with GAD anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friend problems or work difficulties.

Generalized Anxiety Disorder (GAD)•A variety of physical symptoms, including

fatigue, fidgeting, headaches, nausea, numbness in hands and feet, muscle tension, muscle aches, difficulty swallowing, bouts of difficulty breathing, trembling, twitching, irritability, sweating, insomnia, hot flashes, and rashes.

•These symptoms must be consistent and on-going, persisting at least 6 months, for a formal diagnosis of GAD to be introduced.

Epidemiology

•The usual age of onset is variable - from childhood to late adulthood, with the median age of onset being approximately 31

•Most studies find that GAD is associated with an earlier and more gradual onset than the other anxiety disorders

Epidemiology

•One year prevalence = 3-8 %•F:M = 2:1 •Receiving inpatient treatment F:M = 1:1•Lifetime prevalence: 5 %

Aetiology - Biological

•The two most implicated receptor groups are serotonergic & GABAminergic

Genetics:•~25 % of first degree relatives of

sufferers have GAD•Male relatives are more likely to have an

alcohol misuse disorder•Some twin studies report a MZ

concordance of 50 %, and a DZ concordance of 15 %

Aetiology - Psychosocial

•Cognitive behavioural theories suggest that GAD arises from selective attention being given to negative details in the environment, by distortions in information processing, and by an overly negative view of the person’s ability to cope

•Psychoanalytical models hypothesize that anxiety is a symptom of unresolved unconscious conflicts

Risk Factors

•Female gender •Childhood adversity (abuse or trauma,

including witnessing traumatic events)• Illness (chronic health conditions,

cancer)•Stress•Personality•Genetics•Substance use

Course and Prognosis•The clinical course and prognosis are

difficult to predict•Life events are associated with the

onset of GAD•Only 1/3 seek psychiatric help•Many go to non-psychiatrists, seeking

help for somatic symptoms•Generally a chronic disorder, with a

lifelong fluctuating course

Treatment

•Antidepressants

•Buspirone•Benzodiazepines

•Psychotherapy

MCQ 13

•In generalised anxiety disorder we see: 1. Brief episodes of depression 2. Rituals 3. Obsessions 4. Suicide attempts5. Higher dizygotic twin concordance rather

than monozygotic

Panic disorder•Recurrent unexpected panic attacks

with or without agoraphobia•At least one of the attacks has been

followed by 1 month (or more) of one (or more) of the following:▫persistent concern about having additional

attacks▫worry about the implications of the attack

or its consequences (e.g., losing control, having a heart attack, "going crazy")

▫significant change in behaviour related to the attacks

Panic attack

•A panic attack may be defined as a sudden onset of a discrete period of severe anxiety in which at least four or more of the following symptoms have been experienced:1. palpitations2. sweating3. trembling or shaking4. sensation of shortness of breath5. feeling of choking

Panic attack

6. chest pain / discomfort7. nausea / butterflies8. dizziness / lightheadedness9. derealisation / depersonalisation10. fear of losing control / going crazy11. fear of dying12. paraesthesia13. chills or hot flushes

Extended Matching Item

• Options: 1.5 to 3 per cent / 0.6 to 6 per cent / 25 per cent / 5 to 10 per cent / None of the above

Each option might be used once, more than once, or not at all.1. Lifetime prevalence rates for agoraphobia2. Lifetime prevalence rates for panic attacks3. Lifetime prevalence rates for phobias4. Lifetime prevalence rates for PTSD

Epidemiology

•6-month prevalence = 0.6 - 1 %•Lifetime prevalence = 1.5-3 %•F:M = 2:1•Mean age of onset = 25 years old; rare

after the age of 40•Age range 25-44

Aetiology -Biological

•Major neurotransmitter systems involved: Noradrenergic, Serotonergic, GABA

•Genetic studies: 4-8 x increase in panic disorder amongst the relatives of affected probands

Aetiology - Psychosocial

a) Separation in early life (<17)b) Cognitive behavioural theories: anxiety

is a learned response. The genesis and maintenance of panic attacks is explained by a combination of classical conditioning and the negative catastrophic thoughts that patients have during attacks

c) Psychoanalytical models: unsuccessful attempts to defend against anxiety provoking impulses

Course and prognosis• 30-40 % of patients

appear to be symptom free at long term follow up

• 50 % have very mild symptoms

• 10-20 % continue to have significant symptoms

• OCD may develop

Course and prognosis

•Depression may occur in 40 - 80 % of panic patients

•Alcohol and substance dependency may occur in up to 20 - 40 % of patients

•Increased risk of suicide

Treatment

•PsychologicalCognitive behavioural therapy •PharmacotherapyAntidepressants Benzodiazepines

Obsessive Compulsive disorder (OCD)•Characterised by intrusive thoughts that

produce anxiety, by repetitive behaviours aimed at reducing anxiety, or by combinations of such thoughts (obsessions) and behaviours (compulsions).

•The symptoms range from repetitive hand-washing and extensive hoarding to preoccupation with sexual, religious, or aggressive impulses.

Clinical features

•Obsessive thoughts / ideasa) repeated, intrusive thoughts

interfering with normal train of thought, causing distress

b) may be single words, phrases, rhymes, or puns - often violent, obscene or blasphemous

c) attempts to exclude them lead to distress

Clinical features

2. Obsessive imagesa) vivid, not hallucinationsb) often of a violent or sexual nature

3. Obsessive ruminationsendless inconclusive internal debates

4. Obsessive doubtsconcern over actions, e.g. gas not switched

off, doors not closed

Clinical features

5. Obsessive convictionsa) notions that thoughts equal acts e.g. “if I

think about him he will die”b) may be delusional in intensity

6. Compulsive ritualsa) mental rituals such as countingb) physical activities like washing and checkingc) may be related to thoughts, or be

unconnected

Epidemiology

•Lifetime prevalence = 2 - 3 %•M:F = 1:1•Mean age at onset = 20 years•Fourth most common psychiatric disorder

(after phobias, substance related disorders and depression)

Aetiology - Biological

•Dysregulation of serotonin functionGenetic:i) MZ: DZ = 50-80 % : 25 %ii) 35 % of 1st degree relatives also have

OCDiii) between 11-80 % of Tourette’s patients

have obsessional symptoms; 20 % of OCD patients suffer from tics

Aetiology - Psychosocial

•Behavioural theorists: obsessions are conditioned stimuli - compulsions are established as learned avoidance strategies to lessen anxiety

•Personality traits•Psychoanalytical models: OCD arises from

a combination of defence mechanisms protecting the person from conflicting desires and drives

OCD

Defence mechanisms in OCD i) Isolation (separation of an impulse or

idea from its emotional content)ii) Undoing (reversing the consequences of

an action, usually with a compulsive act)iii) Reaction formation (behaving in an

opposite way to your underlying impulses)iv) Magical thinking (everything you think

about comes true)v) Ambivalence (both loving and hating the

same object)

Course and Prognosis

•20-30% significant improvement, 40-50% moderate, the remaining 20-40% remain ill or with worsening symptoms

•~1/3 have depression•Suicide is a risk for all OCD patients

MCQ 14• A woman comes into your outpatient clinic. She

is obsessed with dirt and has to wash her hands up to twenty times if she touches anything. The treatment you would recommend would be: 1. Exposure and Response Prevention 2. CBT 3. CAT 4. Psychodynamic therapy 5. Interpersonal therapy

MCQ 15• John, a 13 year-old boy, has obsessive-compulsive disorder.

He is affected by a number of preoccupying thoughts and rituals. John is able to describe in detail the thoughts and associated fears. He does become frustrated and low in mood at times, but is not clinically depressed. What would you recommend?A. Behavioural therapyB. FluoxetineC. Parenting interventionsD. Family therapyE. MethylphenidateF. Cognitive-behavioural therapy (CBT)G. Individual psychodynamic psychotherapyH. SertralineI. CounsellingJ. Risperidone

Treatment

•Behaviour therapy (Exposure and response prevention)

•Pharmacotherapy (SSRIs, Clomipramine)•Combinations of the above

Post Traumatic Stress Disorder

• Arises as a delayed and / or protracted response to a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

• The event usually involves the threat of severe injury or death, or a threat to physical integrity.

• PTSD is a less frequent and more enduring consequence of psychological trauma than the more frequently seen acute stress response.

PTSD Clinical features

Diagnostic symptoms include re-experiencing original trauma(s), by means of

•flashbacks or nightmares; •avoidance of stimuli associated with

the trauma; and • increased arousal, such as difficulty

falling or staying asleep, anger, and hypervigilance.

PTSD Clinical features

•Formal diagnostic criteria (both DSM and ICD) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.

Phobia

•Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.

•Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack.

Phobia

•The person recognizes that the fear is excessive or unreasonable.

•The phobic situation(s) is avoided or else is endured with intense anxiety or distress. 

Agoraphobia•Anxiety about being in places or

situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack.

•Agoraphobic fears involve characteristic clusters of situations: being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and travelling in a bus, train or car.

Agoraphobia

•The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.

Social Phobia

Social phobia

•A marked and persistent fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

Social Phobia

•Exposure to the social or performance situation provokes an immediate anxiety response. This response may take the form of a panic attack.

•The person recognizes that their fear is excessive or unreasonable.

•The social or performance situation is avoided, although it is sometimes endured with dread (intense anxiety or distress)

Specific Phobias•Animal type e.g. fear of spiders

(arachnophobia) and the fear of snakes (ophidiophobia).

•Natural environment type e.g. fear of heights (acrophobia), the fear of lightning and thunderstorms (astrapophobia), and the fear of aging (gerascophobia).

Specific Phobias• Situational type e.g.

fear of small confined spaces (claustrophobia) and being "afraid of the dark," (nyctophobia).

• Blood/injection/injury type e.g. fear of medical procedures including needles and injections (trypanophobia).

Treatment

•Systematic desensitisation and exposure (for specific phobias) and cognitive behavioural therapy (for social phobias).

•Beta-blockers may be effective in treating performance-anxiety symptoms.

•Drugs used in social phobias include SSRIs (doses higher than those used in depression).

Dissociative disorders

•Conditions that involve disruptions or of memory, awareness, identity and/or perception.

•People with dissociative disorders use dissociation (a defence mechanism), pathologically and involuntarily.

Depersonalisation Disorder

•Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling as though one is in a dream; sense of unreality of self or body; or time moving slowly)

Derealisation Disorder

•Persistent or recurrent experiences of unreality of surroundings (e.g., world around the person is experienced as unreal, dreamlike, distant, or distorted)

•During the depersonalisation or derealisation experience, reality testing remains intact

Dissociative Amnesia•Inability to recall important personal

information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.

(1) Localized amnesia for a specific event or events

(2) Dissociative Fugue: generalized amnesia for identity and life history. Fugue may be accompanied by either purposeful travel or bewildered wandering.

Dissociative Identity Disorder

•The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

•At least two of these identities or personality states recurrently take control of the person's behaviour.

•Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

Dissociative Identity Disorder

Causes and Treatment

•Dissociative disorders are thought to primarily be caused by psychological trauma.

•Treatment: Usually Psychotherapy.

Somatoform disorders

•Somatisation disorder•Undifferentiated somatoform disorder•Conversion disorder•Pain disorder •Hypochondriasis•Body dysmorphic disorder•Somatoform disorder NOS

Somatisation disorder

Conversion disorder

Hypochondriasis

Body dysmorphic disorder

Body dysmorphic disorder

MCQ 16A woman comes to see you in out-patients. She

has a 6-month old son and for the last three months she has recurring thoughts of harming him. She does not wish to harm him and these thoughts make her tearful and anxious. The birth was uneventful but she perceives it to have been traumatic. You diagnose: 1. PTSD 2. Postnatal depression 3. OCD 4. Specific Phobia

Thank you!