Download Depressive & Anxiety disorders

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Functional abdominal pain
syndrome
Irritable bowel syndrome
Chronic pain disorder
(Somatoform disorders)
Depressive & Anxiety disorders
The gut and the brain are highly integrated, and they
communicate in a bidirectional fashion, largely through the (ANS)
and (HPA) axis
• Limbic system:
• internal and external homeostasis of the organism
• central role in emotionality, which is a nonverbal system that
facilitates survival, threat-avoidance, social interaction, and learning
• “mind/body interaction” may largely arise in this region
• “top-down” modulation of visceral pain and visceral perception
• cognitive/psychological factors, visceral perception, and motor
abnormalities
NTs for Depression
• NE – mostly located in the Locus Ceruleus
• 5-HT – mostly located in the Dorsal
Raphe
– Brainstem area with pathways to the neocortex and
limbic system, as well as down the spinal cord
5-HT affects:
Impulsivity
Aggression
Appetite
Sex
Anxiety
Irritability
Pain
Mood
Emotion
Cog Function
NE affects:
Vigilance
Motivation
UTMB Galveston
Baker 2009
Psychosocial correlates of
Irritable Bowel Syndrome
Psychosocial
correlates
Presence in Irritable Bowel Syndrome
Psychiatric
disorders
High rates of psychiatric diagnoses (especially anxiety
disorders) in people with IBS drawn from clinics and the
population.
Personality
dysfunction
High levels of neuroticism and low levels of extroversion
characterise people with IBS drawn from clinics and the
population.
Childhood
abuse
A history of childhood sexual or physical abuse is more
common in people with IBS versus controls, especially
among consulters versus non-consulters with IBS.
Psychosocial correlates of
Irritable Bowel Syndrome
Psychosocial
correlates
Presence in Irritable Bowel Syndrome
Life event stress
Close association between life event stress and the
onset and/or exacerbation of IBS symptoms.
Coping ability
Non-consulters exhibit greater coping capabilities
under stress than consulters with IBS.
Social support
IBS patients have less social support in terms of
tangible assistance compared with healthy controls.
Management of chronic functional
abdominal pain
• Set the agenda
• Provide unambiguous
information about findings
• Time planning: a longer planned
session may save time in long
run-Regular visit
• Identify psychosocial factors
• Empathy
• Set limits for investigations
Don't treat what patient doesn't
have-Do not harm
• Encourage patient to take
responsibility
• Med-psych interfere
•
Approach to patients:
Disease or illness oriented
•
•
•
•
•
Cognition: content, styles, questions.
Emotion
Function
Expectation
Concerns
Pain perception:
Cognition
Ruminations
Catastrophizing
Selective
perception
Nociception
Affect
Depression
Anxiety
Fear
Psychological Treatments:
• Cognitive therapy
• Behavioural therapy
• Interpersonal
therapy
• Dynamic
psychotherapy
• Hypnotherapy
•
Psychological treatments should
not be limited to people with co
morbid psychiatric disorders.
•
Psychological therapy already
exists in routine clinical care and
includes clear explanation and
true reassurance, which helps
patients cope better with their
disorder.
Cognitive behavioural approach
to understanding health anxiety
Probability x
(perceived cost) awfulness
Anxiety =
Perceived ability to cope + chance of help (rescue)
Antidepressant therapy:
• Psychiatric and non psychiatric
disorders: e.g. neuropathic pain
syndromes.
• The analgesic effect is independent and
sooner than antidepressant effect.
The time required to obtain analgesia : 1
day to 10 weeks.
• Drug intolerance is a rule: Start low go
slow (Low doses).
• Aware of potential adverse effects and be
prepared to undertake either dosage
adjustments or trials with other agents.
• No FDA approved antidepressant for
IBS.
• Different kinds of ADs: TCA, SSRIs,
SNRIs, MAOIs.
Tricyclic Antidepressants
• Frequently used
• In contrast, the effective dose range for
TCAs in IBS appears to be about 30–50
(10-70) mg/day of amitriptyline or its
equivalent.
• Unclear mechanism of action
–
–
–
–
Antihyperalgesia
Improved sleep
Normalized bowel transit
Coexisting depression/anxiety at higher doses
Tricyclic Antidepressants
•
•
•
•
•
Inconsistent data on efficacy
– Improved abdominal pain, global symptoms seen in some RCT’s,
systematic reviews
Evidence has significant limitations
– Variable dosing
– Small numbers
– High discontinuation rates
– Short duration
– Poor/variable designs
May exacerbate constipation
– Appears dose related
– Might be more beneficial in patients with diarrhea
Decrease abdominal pain; no improvement in global symptoms
Few head-to-head trials with SSRIs
SSRIs
• None are FDA approved for IBS
• Directly or indirectly affect gut function and
motility.
• Analgesic properties.
• Effective in a variety of somatoform disorders
and alleviate global distress.
• Extra intestinal symptoms.
• Affective memory bias towards positive
material.
•
Few RCTs of use in IBS: suggest improvement well being, pain, QOL scores
• No superiority of one SSRIs.
• Among SSRIs, evidence is available for paroxetine,
paroxetine CR, fluoxetine and citalopram.
• Target dose of SSRIs in IBS appears is in the range
found to be efficacious in the treatment of
depression.
• SSRI trials should be at least 8–12 weeks in
duration of IBS.
• If patients demonstrate clinical benefit; continue
the medications for at least 6–12 months.
• A gradual reduction in dose: pay attention to
withdrawal symptoms
• Close monitoring of patients for recurrence of
symptoms-Withdrawal syndrome
• Co morbid anxiety or depression: long-term
treatment with antidepressants.
• Failure to respond to one antidepressant,
switching to another antidepressant.
SNRI
• Effective in decreasing pain in other
chronic conditions
• No trials yet on effect in IBS
Insufficient evidence to make
recommendations about SNRIs (e.g.
venlafaxine - doluxetine) in IBS.
• Mechanisms of action: SER- NE Reuptake
inhibition