Common Common Psychiatric Psychiatric

Problems In PHCProblems In PHC

Done by;ZAID ALMUBARAKYAZEED ALSUBAIE

The prevalence of anxiety, depression and somatization in Saudi Arabia

The etiology of anxiety, depression and somatization

Clinical features and management in family medicine setting

Use of Tricyclic antidepressants (TCA) and Selective serotonin reuptake inhibitors (SSRIs)

Counseling and psychotherapy

Referral

MCQs

1- A 41-year-old man presented with a 3-week-history of lack of motivation, fatigue, excessive self blame, poor appetite, social isolation, and delaying his tasks. He has no previous history of psychiatric or medical disorders. What is the most likely diagnosis?

a) Major Depressive Disorder, recurrent type.

b) Dysthymic disorder.

c) Major depressive Disorder, single episode.

d) Depression due to underlying medical problem.

MCQs

2- A depressed patient should be referred to psychiatric clinics when the patient displays:

a) Loss of appetite

b) Fatigue

c) Diminished pleasure

d) Suicidal thoughts

MCQs

3- In order to diagnose General Anxiety Disorder (GAD), the symptoms of anxiety and excessive worrying must be present of at least:

a) Month

b) 3 Months

c) 6 Months

d) 1 Year

MCQs

4- According to DSM V criteria for diagnosing mental disorders a patient showing 3 to 4 depressive symptoms over a period of more than two years is diagnosed with:

a) Minor depression

b) Major depression

c) Dysthymia

d) Bipolar depression

MCQs

5- Somatization usually occurs with:

a) Medical diseases/Physical diseases

b) Anxiety disorders or/and depression

c) Neurodevelopmental disorders

Depression

Case Scenario

Ms. Amal is a 27-year-old single woman works as a teacher. She has a five-week history of low mood, chest tightness, poor appetite, disturbed sleep, excessive guilt feelings, and loss of interest in her social activities. Her father has a history of mood disorder.

Definition

Depressive disorders are characterized by persistent low mood, loss of interest and enjoyment, neurovegetative disturbance, and reduced energy, causing varying levels of social and occupational dysfunction.

prevalence of depression

According to the World Health Organization (WHO), depression is a common mental health disorder, affecting more than 350 million people of all ages worldwide. In 2001, the WHO identified depression as the fourth leading cause of disability and premature death in the world. It is projected to become the leading cause of burden of disease by 2030.

World Health Organization notes more than 75% of people with depression in developing countries are inadequately treated.

A new study found that the Middle East, including Saudi Arabia has a very high rate of major depression compared with the rest of the world - almost 7%.

Etiology of Depression

GENETIC FACTORS

PSYCHOLOGICAL

As supported by family and twin studies

BIOLOGICAL

Reduced level of NE,5HT, &DA.

•Stressful events.•Premorbid personality factors.•Cognitive distortions

The causative are multifactorial

Classifications of Depression

According to the DSM Classification :

o Major Depressive Disorder. o Dysthymic Disorder (Chronic Depression).

o Postpartum Depressive Disorder.

o Seasonal Depressive Disorder (Usually in Winter)

o Unspecified Depressive Disorder

Clinical Features

A. Mood Changes :

1. Feeling low.

2. Lack of enjoyment and inability to experience pleasures (Anhedonia).

3. Irritability (Bad Mood).

4. Frustration (Defeated or Nothing is Right).

5. Tension (Under Pressure).

Clinical Features Cont.

B. Appearance & Behavior :

1. Neglect Look (dress, hair… etc.).

2. Facial Appearance of Sadness: Tearful eyes. Reduced rate of blinking. Head is inclined forwards. Down cast gaze. Turning downwards of the corners of the

mouth.

3. Psychomotor Retardation (slow movements & interactions).

4. Social Isolation and Delay of Tasks.

Clinical Features Cont.

C. Biological Features :

1. Changes in Sleep, Appetite and Weight (Increase/Decrease).

2. Low Energy.

3. Low Libido.

4. Change in Bowel Habit (Constipation).

5. Change in Menstrual Cycle (Amenorrhea).

6. Diurnal Variation of Mood (Worse at Morning).

7. Several Immunological Abnormalities (Low Lymphocytes which increase the risk of infection).

Clinical Features Cont.

D. Cognitive Features (Thinking):

1. Poor Attention, Concentration and Memory.

2. Remembering Negative Memories, Feeling Guilty, Not Seeing a Future and Negative Thinking of the Present.

E. Psychotic Features :

1. Delusions (Guilt, poverty or lost functions of body … etc.).

2. Hallucinations (Hearing sounds or sense death).

Major Depressive Disorder

Criteria for Major Depressive Disorder :

A.Presence of a single or more major depressive episode.

B.There has never been a manic episode, a mixed episode, or a hypomanic episode.

Major Depressive Episode (MDE) Duration ≥ 2-weeks

5 of the following symptoms:

1. Low mood. 2. Loss of interest.

3. Appetite or body weight change (increased or decreased). 4.Insomnia or hypersomnia. 5. Psychomotor agitation or retardation. 6. Fatigue or loss of energy. 7. excessive guilt. 8. Diminished concentration. 9. Recurrent thoughts of death or suicide.

at least one of the symptoms is either no.1 or no.2

Significant impairment in functioning.

Not due to substance abuse , a medication or a medical condition (e.g., hypothyroidism).

DYSTHYMIC DISORDERDiagnostic Criteria:

2 of the mentioned clinical features for at least 2 years.

During the 2 years the has to be no major depressive episode.

There has never been a manic episode, a mixed episode, or a hypomanic episode.

The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

Management plan

1. Admission or not?

2. Education and Reassurance.

3. BioPsychoSocial approach.

Indications for admission

1. Danger to self

2. Danger to others

3. Total inability to function

4. Drug resistance cases

5. Observation and clarify Diagnosis

Full clinical response in 6-8 weeks in major depression disorder.

SSRIUses:•Depressive disorders.•Anxiety•phobia •panic disorders.•Obsessive compulsive disorder.•Premature ejaculation.

S/E• Headache

• Nausea

• Stomach ache

• Decrease libido

• Wight gain

• Sedation

Uses:Depressive disorders.Anxiety.Obsessive compulsive disorder.Tricyclics are dangerous in overdose and should be avoided with suicidal patients.

S/E Headache Nausea / vomiting Dry mouth Constipation Cardiac problems Decrease libido sedation

TCA

Prognosis

Depends on:

Dx Severity Duration Support Compliance Approximately 20 weeks for recovery. Relapse in 25% of patients.

Anxiety

Case Scenario

Ali, 45 year old, locksmith. He has longstanding and persistent worries that he has not done his job properly. He worries he might have given customers the wrong change whenever they have paid him in cash. Ali informs you that he worries about many things in his life, and his most common thought is ‘what if’?

Case Scenario

He often imagines the worst happening and states that when he worries, he often feels sick, has headaches, feels butterflies in his stomach and is aware of his heart pounding. Ali often gets hot and sweaty and says his symptoms makes it difficult to concentrate and do his job. He is very distressed by his constant worrying and regards it as a sign of weakness

Definitions

• Anxiety: subjective feeling of worry, fear, and apprehension accompanied by autonomic symptoms, caused by anticipation of threat/danger.

• Anxiety disorders: are a group of abnormal anxiety states not caused by an organic brain disease, a medical illness nor a psychiatric disorder.

• Generalized anxiety disorder (GAD): is characterized by excessive and persistent worrying that is hard to control, causes significant distress or impairment.

Types Of Anxiety Disorders:

Generalized Anxiety Disorder (GAD)

Panic Disorder.

Agoraphobia.

Social Phobia.

Specific Phobia

Prevalence in KSA

A cross-sectional study was conducted to estimate the prevalence of mental health problems among Saudi university students in Saudi Arabia. The sample size was 1696 students of both genders from ten colleges.

Study result: generalized anxiety disorder was reported in 14% of the Saudi students.

Etiology

The actual cause of generalized anxiety disorder is unknown, but many factors can contribute to the development of generalized anxiety disorder including:

Genetic factors Environmental factors: such as stress and trauma Developmental factors: exposure to traumatic

experiences in childhood Metabolic factors: such as hyperthyroidism

Symptoms & signsFeatures of Anxiety:

Psychological Physical

Excessive worries & fearful anticipation.

Chest: chest discomfort & difficulty in inhalation.

Feeling of restlessness/irritability.

Cardiovascular: palpitation &cold extremities.

Hypervigilance. Neurological : tremor, headache, numbness

Difficulty concentrating. Gastrointestinal: disturbed appetite, dysphagia, epigastric discomfort &

disturbed bowel habits.

Subjective report of memory deficit.

Genitourinary: increased urine frequency, low libido, erectile

dysfunction, impotence & dysmenorrhea.

Sensitivity to noise. Musculoskeletal: muscle tension, joint pain, easily fatigued.

Sleep: insomnia / bad dreams. Skin: sweating, itching, hot & cold skin.

Diagnosis

DSM-IV Diagnostic Criteria for GAD:DSM-IV Diagnostic Criteria for GAD:

A. At least 6 months of "excessive anxiety and worry" about a variety of events and situations.

A. There is significant difficulty in controlling the anxiety and worry.

B. functional impairment in social/ occupational/ or other areas

Diagnosis con.

D. The anxiety and worry are associated with ≥ 3of 6

Restlessness easily fatigued. Difficulity concentrating. Irritability muscle tension Sleep disturbance.

E. Not caused by other psychiatric , medical or substance abuse conditions.

Management An important part of any intervention with a

patient with an anxiety disorder is education.

Rule out medical causes.

In general, anxiety disorders are treated with Cognitive-Behavior Therapy (CBT), medication or both.

Treatment choices depend on the problem and

the person’s preference.

Cognitive Behavioral Therapy;

Cognitive component;

Detection and correction of wrong thoughts & illogical ways of reasoning .

Behavioral component;

Relaxation training.

Exposure to feared situation.

The patient is trained to overcome avoidance.

Pharmacotherapy

Antidepressants :First-line Medications: Selective-serotonin Reuptake Inhibitors (SSRIs) (e.g. paroxetine 20mg) SNRIs ( e.g. Venlafaxine 150mg). Second-line Medications:  Tricyclic Antidepressants (TCAs)Benzodiazepines: Acute Management, for

a limited period (to avoid the risk of dependence),

Somatoform disorder

Somatic Symptom and Related Disorders (DSM -5)

Case scenario

A 25-year-old female college student sought medical attention for recurrent multiple somatic complaints. Her list of symptoms included gastrointestinal difficulties, painful menstruation, nausea, weakness, malaise, fatigue, headaches, back pain, and disturbed sleep. During the assessment, a complete history was taken of the current symptomatic complaints, associated symptoms, and behaviors, Information was also obtained about her childhood, family, education, and medical, and psychiatric treatment. The history revealed that she remembers a normal childhood and that she is close to her mother.

Physical problems, which the client considered minor at that time, started during her last year of high school and continued to worsen to the present. Her mother took her to numerous physicians in an attempt to find solutions to her complaints. As a result, narcotics were prescribed and the client developed an addiction. Furthermore, exploratory laparotomies and multiple diagnostic procedures were performed, yet no organic cause was found. She expressed frustration that several doctors told her that she was a chronic complainer who didn’t have anything wrong with her.

What are Somatoform disorders ? Are a group of disorders in which physical symptoms are the main complaints and cannot be explained fully by a medical condition, a direct effect of a substance or a mental disorder.

Types of somatoform disorders:Somatization disorderHypochondriasisBody dysmorphic disorder.Conversion disorderPain disorder.

Somatization disorder

Somatization disorder is a chronic condition in which a person has physical symptoms that affecting multiple organs system.

Can not be explained adequately based on physical examination and laboratory investigations.

The symptoms are not intentionally produced.

It is a associated with excessive medical help-seeking behavior.

It can leads to significant distress and functional impairment (social, occupational...).

Prevalence of Somatization Disorder in Saudi Arabia

A study was conducted in a primary health care in Saudi Arabia to assess the prevalence of somatization disorder.

The sample size was 224 including 104 males and 120 females.

The prevalence of somatization was 16%.

Women displayed higher levels of somatization than men.

Clinical features

Pain symptomsheadache, chest pain, abdominal pain, back pain, joint pain, painful

urination (dysuria), painful sexual intercourse and painful menstruation (dysmenorrhea).

GI symptomsnausea, vomiting, difficulty in swallowing and diarrhea

Cardiopulmonary symptomsshortness of breath (dyspnea), and palpitation.

Other symptomsdizziness, double or blurred vision

SOMATIZATION DISORDER

Management A strong doctor-patient relationship is a key

to getting help with somatoform disorders. Seeing a single health care provider with

experience managing somatoform disorders can help cut down on unnecessary tests and treatments.

The focus of treatment is on improving daily functioning, not on managing symptoms.

Stress reduction is often an important part of getting better. Counseling for family and friends may also be useful.

Management

Cognitive Behavioral Therapy;

helps relieve symptoms associated with somatoform disorders. The therapy focuses on correcting:

distorted thoughts unrealistic beliefs behaviors that prompt health anxiety

HypochondriasisPeople with this type are preoccupied with concern they have a serious disease. They may believe that minor complaints are signs of very serious medical problems.

For example, they may believe that a common headache is a sign of a brain tumor.

Body dysmorphic disorder•People with this disorder are obsessed with a physical flaw. Patients may also imagine a flaw they don't have.•The worry over this trait or flaw is typically constant. It may involve any part of the body.

Conversion disorder

Conversion disorder. This condition strikes when people have neurological symptoms that can't be traced back to a medical cause. For example, patients may have symptoms such as:

paralysis blindness hearing loss loss of sensation or numbness Stress usually makes symptoms of

conversion disorder worse.

Pain disorder

People who have pain disorder typically experience pain that started with a psychological stress or trauma.

For example, they develop an unexplained, chronic headache after a stressful life event.

Management of Common Psychiatric Problems: Counseling

Consoling helps people to solve stressful problems by decision making.

The counselor’s role: helping the patient to choose decision among alternative courses of actions

Management of Common Psychiatric Problems: Psychotherapy

Psychotherapy: is a therapy used to treat people with a mental disorder by teaching them strategies and giving them tools to deal with stress and unhealthy thoughts and behaviors.

Cognitive Behavioral Therapy (CBT): is one of psychotherapy types and it aims to change a person's thinking to be more adaptive and healthy. Behavioral therapy focuses on a person's actions and aims to change unhealthy behavior patterns.

Cognitive behavioral therapy can be applied to treat many mental disorders such as:

Depression.

Anxiety disorder.

Somatiforme disorder.

When to refer a patient to a psychiatrist?

Suicidal patients Psychotic symptoms Substance abuse/addiction Sleep problems Desire to treat the patient with psychotherapy or

electroconvulsive therapy

MCQs

1- A 41-year-old man presented with a 3-week-history of lack of motivation, fatigue, excessive self blame, poor appetite, social isolation, and delaying his tasks. He has no previous history of psychiatric or medical disorders. What is the most likely diagnosis?

a) Major Depressive Disorder, recurrent type.

b) Dysthymic disorder.

c) Major depressive Disorder, single episode.

d) Depression due to underlying medical problem.

MCQs

2- A depressed patient should be referred to psychiatric clinics when the patient displays:

a) Loss of appetite

b) Fatigue

c) Diminished pleasure

d) Suicidal thoughts

MCQs

3- In order to diagnose General Anxiety Disorder (GAD), the symptoms of anxiety and excessive worrying must be present of at least:

a) Month

b) 3 Months

c) 6 Months

d) 1 Year

MCQs

4- According to DSM V criteria for diagnosing mental disorders a patient showing 3 to 4 depressive symptoms over a period of more than two years is diagnosed with:

a) Minor depression

b) Major depression

c) Dysthymia

d) Bipolar depression

MCQs

5- Somatization usually occurs with:

a) Medical diseases/Physical diseases

b) Anxiety disorders or/and depression

c) Neurodevelopmental disorders

References M. A. Al-Sughayir - Manual of Basic Psychiatry

Sartorius N, Ustun B, Silva J, Goldberg D, Lecrubier Y, Ormel J et al. An International Study of Psychological Problems in Primary Care: Preliminary Report From the WHO Collaborative Project on ‘Psychological Problems in General Health Care’. Arch Gen Psychiatry 1993; 50: 819-

Prevalence of mental illness among Saudi adult primary-care patients in Central Saudi Arabia Abdallah D. Al-Khathami, MBBS, ABFM, Danny O. Ogbeide, FWACP, FRCGPSaudi Med J 2002; Vol. 23 (6) www.smj.org.sa

Oxford Handbook Of Psychiatry 2nd Edition

American Academy of Family Physicians www.aafp.org/afp/2009/0501/p785

National Institute For Health And Clinical Excellence www.nice.org.uk/nicemedia/live/13476/59320/59320.pdf

Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, World Health Organization (http://www.who.int/mental_health/evidence/atlas/profiles/sau_mh_profile.pdf?ua=1 )

Rates of Depression in The Middle East Alarming (http://www.saudihealthexhibition.com/en/Industry-News/Rates-of-Depression-in-The-Middle-East-Alarming-/ )

Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, World Health Organization (http://www.who.int/mental_health/evidence/atlas/profiles/sau_mh_profile.pdf?ua=1 )

Rates of Depression in The Middle East Alarming (http://www.saudihealthexhibition.com/en/Industry-News/Rates-of-Depression-in-The-Middle-East-Alarming-/ )