Download Mood Disorders for MRCPsych Part I

Mood Disorders –
Anxiety Disorders
MRCPsych Paper 3
Dr Nicoletta P. Lekka
Consultant 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
abandonment
2. Anxiety
3. Loss of interest & enjoyment
4. 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
self
2. It does not result from loss
3. It protects the ego against despair
4. 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 factors
Obsessive-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 abuse
3. Anxiety disorder symptoms
4. Absence of psychotic symptoms
5. 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 presentations
Atypical depression
• Sometimes called masked depression
• Usual mood symptoms are not prominent
Presentations 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 Symptoms
As 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 68 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
admission
2. Flight of ideas/ thought racing
3. Psychotic features
4. Inflated self-esteem/ grandiosity
5. 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 1year 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 9
Which 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 weeks
C. More than 80% of manic episodes last more than
1 month with treatment
D. More than 90% of manic episodes last more than
1 month with treatment
E. 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.
B.
C.
D.
E.
CBT
SSRI
CBT and SSRI
TCA
ECT
MCQ 11
What would you do for a patient with
depression and no improvement after two
months on 50 mg of Sertraline:
A.
B.
C.
D.
E.
Increase the Sertraline
Change to a different SSRI
Add an antipsychotic
Switch to Venlafaxine
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%)
•
•
•
•
Alcohol & Substance Misuse
Use of antidepressants (esp. induced mania)
Hypothyroidism
Other Medical conditions: CVA, Head injury, MS
• Risk factors:
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 12
Which 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
Agoraphobia
Social 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 ongoing, 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 attempts
5. 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. palpitations
2. sweating
3. trembling or shaking
4. sensation of shortness of breath
5. feeling of choking
Panic attack
6. chest pain / discomfort
7. nausea / butterflies
8. dizziness / lightheadedness
9. derealisation / depersonalisation
10. fear of losing control / going crazy
11. fear of dying
12. paraesthesia
13. 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 agoraphobia
2. Lifetime prevalence rates for panic attacks
3. Lifetime prevalence rates for phobias
4. 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
• Psychological
Cognitive behavioural therapy
• Pharmacotherapy
Antidepressants
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 handwashing and extensive hoarding to
preoccupation with sexual, religious, or
aggressive impulses.
Clinical features
• Obsessive thoughts / ideas
a) 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 images
a) vivid, not hallucinations
b) often of a violent or sexual nature
3. Obsessive ruminations
endless inconclusive internal debates
4. Obsessive doubts
concern over actions, e.g. gas not switched off, doors
not closed
Clinical features
5. Obsessive convictions
a) notions that thoughts equal acts e.g. “if I think about
him he will die”
b) may be delusional in intensity
6. Compulsive rituals
a) mental rituals such as counting
b) physical activities like washing and checking
c) 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 function
Genetic:
i) MZ: DZ = 50-80 % : 25 %
ii) 35 % of 1st degree relatives also have OCD
iii) 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.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Behavioural therapy
Fluoxetine
Parenting interventions
Family therapy
Methylphenidate
Cognitive-behavioural therapy (CBT)
Individual psychodynamic psychotherapy
Sertraline
Counselling
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 16
A 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!