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AFFECTIVE & ANXIETY SPECTRUM DISORDERS

Psychiatry 2 – Practical # 3

Psychiatrická klinika LFUK a UNB, Bratislava

Podporené grantom KEGA č. 099UK-4/2012

Authors: MUDr. Viktor SegedaMUDr. Barbora Vašečková

Supervisor: doc. MUDr. Ján Pečeňák, CSc.

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Affective (mood) disorders

Characterized by disturbance of mood Pathological mood: inadequately deep, intensity, duration,

uncorrectable, without insight, influence on other mental functionsDepressionManiaCombination of both

Severity

Psychotic / non-psychotic

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DEPRESSIVE SYNDROME

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Depressive syndrome

Alteration of mood Alteration of thinking Inhibition of psychomotor activity

Sad, hopeless, anhedonia, morning pessimum, unability to express emotions, anxiety

BradypsychismDepressive content

HypobuliaHypoactivity

+ other symptoms: reduction of interests, reduced libido, suicidal behaviour, loss of energy, psychotic symptoms

+ somatic signs: dyssomnia, hyporexia, pain (headache, lumbalgia, trepidation of extremities…)

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Depressive patient --general appearance

Hypomimics, inhibition of movement, reduced gesticulation (hypokinesis), sadness, poor eye contact

Typical sign – Veraguth's fold

Shorter, 2009

Depressive syndrome –typical patient statements

Feelings:...Overwhelmed, Guilty, Down, Depressed, Frustrated, Unhappy,

Without confidence, Miserable, Sad, Indecisive, Irritable...

Thoughts:...I'm guilty, Everything is my fault, I am useless, Nothing good

happened to me, Life is not worth living...

Behaviour: ...I do not want to go out, to work or school, I am not enjoying activities,

I would like to be isolated...

Physical signs: ...I am tired all day long, sleep problems, loss of apetite, weight loss or

gain, headaches, pain...

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Deppression – questionnig

About mood:

In the past period, have you been feeling sad or unhappy? Does the feeling lift at all if something good happens? Did anyone say you looked sad or down? Has it been hard for you to laugh or smile in the past week? Have you felt tense, anxious or nervous? Have you felt panicky? How

often? How hard has it been to control these feelings? When was the last time you were well?

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About thoughts and emotions:

Have you been putting yourself down, feeling that you are a failure in some way, have you been blaming yourself, feeling guilty or as if you have done something bad?

Have you been less interested in things around you, or in activities you used to enjoy?

Has there been any change in your ability to feel emotions? Have your feelings towards family and friends changed at all?

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Deppression – questionnig

About behaviour: Have you had any trouble getting started at things, at simple routine everyday

things?

About suicidality: Have you felt like life is not worth living? Have you had thoughts of hurting or

even killing yourself? Have you made plans, preparations?

About physical signs: Have you had trouble falling asleep, stay asleep? Have you awakened earlier?

Does food taste as good as usual? Have you had to push yourself to eat?

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Deppression – questionnig

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MANIC SYNDROME

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Manic syndrome

Expansive mood Acceleration of thinking

Acceleration of psychomotor activity

tachypsychismhyperbuliahyperactivity

+ other symptoms: A lot of interests, insomnia, agressive behaviour, a lot of energy, reduced attention, inappropriate sexual encounters, psychotic symptoms.

Exhilaration, happiness, euphoria, overoptimistic ideation, confidence, grandiosity, overfamiliarity

Contents of thinking

expansive contents, can be delusional

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Manic patient – general appearance

Overdressed, poorly dressed, garish make-up, bizarre decorations

Hyperactive, restless, sometimes motor excitement, increased gesture, irritable or familiar, inappropriate during interview, can be hostile, uncooperative

Talkative, increased speed rate, amount, difficult to interrupt, often continuous speech

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Manic syndrome –typical patient statements

I feel absolutely great, I am full of energy! Everything is perfect, I have so many plans and ideas

my friend… I do not need sleeping at all... Let me out of hospital! I will not stay here because I do

not need this, I am healthy… My sexual life is best ever I feel so good, I don´t need any treatment

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Mania – questionnig

Have you been more active last days than usually (at work, social, sexual life)?

What ideas and plans do you have and what have you already done?

How many hours a day do you sleep? Do you feel more irritable? Do you feel like you had more energy?

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AFFECTIVE EPISODES / DISORDERS

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Depressive episode

At least 4 characteristic symptoms Present for at least 2 weeks

Not secondary to the effects of drug/alcohol misuse, medication, somatic disorder, bereavement

May cause significant distress and/or impairment of social, occupational or general functioning

Severity: mild, moderate, severe (depends on number of symptoms,degree of social/occupational impairment, psychotic symptoms)

Suicide rate for severe depressive episode up to 13 %

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Manic episode

Abnormal and persistent change of mood (elevated, expansive, dysphoric, euphoric, irritable)

3 or more other characteristic symptoms of mania (manic syndrome) Should last at least 1 week, or less if hospitalization is necessary

Affects occupational and social functioning Psychotic symptoms may be present

Hypomanic episode 3 or more characteristic symptoms not as severe as in mania, lasting at least

4 days Does not dramatically interfere with social or occupational functioning Does not require hospitalization

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Classification of affective disorders –ICD 10 (F30-F39)

F30: Manic episode (hypomania, mania without/with psychotic signs, other, unspecified

F31: Bipolar affective disorder: current episode hypomanic, manic, depressive

F32: Depressive episode mild, moderate, severe without/with psychotic signs

F33: Recurrent depressive disorder: current episode mild, moderate, severe without/with psychotic signs, in remission

F34: Persistent mood (affective) disorders: Cyclothymia Dysthymia Other persistent mood (affective) disorders Persistent mood (affective) disorder, unspecified

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Special forms of depression

Seasonal affective disorder Post partum depression Alcoholic depression Organic depression Epileptic depression Schizophrenic depression

Affective disorders – workup

Laboratory tests: important are levels of thyroid hormones (triiodothyronine, thyroxine, thyroid-stimulating hormone)

Psychodiagnostic tests; Scales CT of the brain

Differential diagnosis: depressive syndrome often universal, manic syndrome – be aware of organic disorders and intoxications

Schizoaffective disorder (schizophrenic symptoms not always present) Personality disorder Schizophrenia Comorbidity with alcohol/drug abuse Organic damage of the brain Somatic illness (hypothyroidism, anemia, endocrine disease) Medication-induced (typical antipsychotics, glucocorticoids, interferone)

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Affective disorders – treatment principles

Prevention of suicidal / aggresive behaviour Reduction of lenght of episode Alleviation of suffering of the patient Improvement of social/occupational functioning Prevention of chronification / consequences Prevention of cognitive impairment

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Treatment – depression Psychopharmacotherapy: Antidepressants Mood stabilisers Antipsychotics Anxiolytics

Biologic therapy: ECT Phototherapy rTMS Stimulation of n.vagus

Psychotherapy

Psychopharmacotherapy: Antipsychotics Mood stabilisers Anxiolytics

Biologic therapy: ECT

Psychotherapy

Treatment – mania

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ANXIETY DISORDERS

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Anxiety disorders

Anxiety: unpleasant emotional status, unspecified fear, cause can not be exactly identified, vegetative symptoms, can lead to exhaustion

Fear: connection with a specific danger

Combinations of mental and physical symptoms of anxiety without real danger

Affect personal and social functioning, risk of substance abuse Severity: from mild to panic attacks Course: sudden, gradually developing, fluctuating Phobic anxiety: in specific situations, predictable Anticipatory anxiety: even if just thinking about specific situation

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Anxiety disorders –classification – ICD-10

(F40) Phobic-anxiety disorders AgoraphobiaSocial phobias Specific (isolated) phobias

(F41) Other anxiety disordersPanic disorder (episodic paroxysmal anxiety)Generalized anxiety disorderMixed anxiety and depressive disorder

(F42) Obsessive-compulsive disorder (F43) Reaction to severe stress, and adjustment disorders (F44) Dissociative (conversion) disorders

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Panic attack

Anxious mood Vegetative symptoms

Tachycardia, palpitation, dyspnoea, hyperventilation, vertigo, nausea, sweating, tremor, erythema

nonspecific , diffused fear, higher intrapsychic tension, doubts

•Paroxysm of massive anxiety•Periodicity•Solitary/cumulated•Lasts up to 1 h•Often unpredictable

I have heart attack...I am dying ...

I am going to faint ...I am getting mad...

Phobic-anxiety disorders

Fear of usually well defined situations that are not dangerous at that moment

Avoidance of such situations

Anticipatory anxiety

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Agoraphobia

Characterized by anxiety in situations where the sufferer perceives certain environments as dangerous or uncomfortable, often due to the environment's vast openness or crowdedness.

These situations include, but are not limited to: wide-open spaces uncontrollable social situations such as the possibility of being met in

shopping malls, airports, and on bridges „....I'm going to die, to faint, to get lost in space...“

Usually starts in the third decade, chronification with better and worse periods, in 50% chronic symptoms, social dysfunction, can lead to depressive episodes and substance abuse.

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Social phobia

Strong and permanent fear of one or more social situations Fear of being evaluated by others, fear of being criticized Can lead to panic attack

„....I can not hold on, I will be shaking, I will be red, It will be embarrassing, I do not know what to say...“

Typically starts in adolescence, lasts a lifetime, symptoms improve with age, development of alcohol dependence

More often single people, with low education, without children, with low social status

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Generalized anxiety disorder

Free floating anxiety (at least 6 months) Intrapsychic tension Doubts and worries about the family Insomnia Vegetative symptoms Chronic course, low remission rates (30 % within 3 years)

Obsessive-compulsive disorder Characterised by obsessions (egodystonic intrusive thoughts) and

compulsions (repetitive acts aimed to reduce the anxiety) or combination of both

Typical obsessions Contamination Control Guilt Catastrophes, disasters Religious or sexual

Typical compulsions Washing or cleaning Repeated checking Hoarding Praying, repeating differernt acts(opening, closing...) rituals

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OCD – questionning

Do you wash or clean a lot? Do you check things a lot? Do you have thoughts that keep bothering you that you would like to

get rid of but cannot? Do your daily activities take a long time to finish? Are you concerned about putting things in a special order or are you

upset by mess? Do these problems trouble you?

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Anxiety disorders – workup

Questionnaires and scales: Sheehan, Hamilton, Beck anxiety rating scales

Laboratory tests: EKG, EEG, neurologic examination, CT

Differential diagnosis: Exclude somatic disease, intoxication

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Anxiety disorders – treatment principles

Psychotherapy:Cognitive-behavioral therapy (CBT)ATSystematic desensitization

Psychopharmacotherapy:Antidepressants: SSRI, SNRIBenzodiazepine/nonbenzodiazepine anxiolytics

Panic attack: BZD with rapid onset(diazepam, alprazolam), breathing into a plastic sachet, observation

Any questions?

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