Depression and Anxiety Where to go? By Soheir H. ElGhonemy Assistant Professor of Psychiatry, MD in Psychiatry, Arab Board in PsychiatryMember of International Society of Addiction Medicine
CNS: (Brain And Spinal Cord)Brain: It is a large soft mass of nerve tissue that is contained inside a vault of bone called the cranium. The brain monitors and regulates unconscious bodily functions like breathing and heart rate, coordinates most of voluntary movements. It is also the area of consciousness, thought and creativity.
Spinal Cord: The spinal cord is housed in a vertebral bony vault for its own protection. The spinal cord serves as the pathway for nervous impulses to and from the brain. It is also the center of reflexive actions. Both brain and spinal cord are surrounded with the meninges (pia, arachnoid, dura maters) and cerebrospinal fluid.
Brain stem: It is a region continuous with the spinal cord which is Linked to the Diencephalons and Cerebral Cortex. Controlling life sustaining issues i.e.; breathing, sleep circulation and digestion.Cerebellum: Attached to the top of the brain stem. Coordinates sensory inputs from the inner ear and the body muscles to provide accurate control of position, balance and movements
Diencephalon Located just above the brain stem tucked within the interior of the Cerebral hemispheres.Consists of two main components; thalamus and hypothalamus.The thalamus :is involved in screening out the insignificant signals and relaying the important sensory info to the appropriate part of the cortex.
The Hypothalamus;Homeostasis via the regulation of autonomic(unconscious) functions; body temperatures,heart rate, blood pressure.Emotional expression .Control release of hormone from pituitary glandRegulation of food and water intake
Limbic system:It is a series of nerve pathways in cooperating structuressuch as hippocampus and the amygdala , lies withinthe temporal lobes. these structures connect with thecerebral cortex, Diencecephalon and brain stem.Function:Control of appetite.Storage of memory.Expression of mood and emotions.
Neurons:Neurons are the conducting cells of the nervoussystem. A typical neuron consists of a cell body,containing the nucleus and the surroundingcytoplasm; several short radiating processes(dendrites); and one long process (the axon),which terminates in twig like branches and mayhave branches projecting along its course.
Synapse:Synapses allow nerve cells to communicate with oneanother through axons and dendrites, convertingelectrical impulses into chemical signals.Chemical synapses are specialized junctions throughwhich the cells of the nervous system signal to eachother and to non-neuronal cells such as those inmuscles or glands. They are crucial to the biologicalcomputations that underlie perception and thought.They provide the means through which the nervoussystem connects to and controls the other systems ofthe body.
ReceptorA receptor is a protein on the cell membrane or within the cytoplasm or cell nucleus that binds to a specific molecule (a ligand); such as a neurotransmitter, hormone…..etc, and initiates the cellular response to the ligand. Ligand-induced changes in the behavior of receptor proteins result in physiological changes that constitute the biological actions of the ligands.
Receptors exist in different types, dependenton their ligand and functionI. Peripheral membrane proteins.II. Transmembrane proteins, are embedded in the lipid bilayer of cell membranes as Dopamine receptor.III. Intracellular proteins such as those for steroid hormone receptors.
Neurotransmission:Transmission Of information is carried Out by an“electrochemical Process”.In this process the neuron Is electricallypolarized & depolarized and thereby Carries“electric impulses” from the cell body to the axonterminals.These impulses pass to the post-synaptic neuronacross the synaptic cleft “a slight gap acrosswhich the signal must be transmitted”
NeurotransmitterNeurotransmitter is the chemical manufacturedin the neuron that aid in the transmission ofinformation throughout the body.u Excitatory neurotransmitter.r Inhibitory neurotransmitter.
Major neurotransmitters1. Biogenic amines; catecholamineDopamine Excitatory Controls complex movements, motivation, cognition, regulates emotional response.Norepinephrine Excitatory Causes changes in attention, learning and memory, sleep and wakefulness, moodEpinephrine Excitatory Controls fight –flight response
1. Indolamines Controls food intake, sleep, wakefulness, temperature regulation,Serotonin Inhibitory/ Excitatory pain control, sexual behaviors, regulation of emotion Controls alertness, gastric secretions,Histamine Neuromodulators cardiac stimulation, peripheral allergic responses.
DOPAMINE PATHWAYS Basal Nucleus Ganglia accumbens a Substantia b c nigra hypothalamus d Tegmentum
The D4 receptor has the followingvariants D4.2, D4.3a, D4.3b, D4.4a, D4.4b,D4.4c, D4.4d, D4.4e, D4.5a, D4.5b, D4.6a, D4.6b,D4.7a, D4.7b, D4.7c, D4.7d, D4.8, D4.10.
Diagnostic SystemsA classification system provides a common language with which all mental healthcare professionals can communicate about similar patients in various different places or countries.Crucial for administrative and legal documentation and also for research purposes.
Diagnostic and Statistical Manual of Mental Disorders - 4th editionDeveloped and printed by the APA (American PsychiatricAssociation)Only applicable to mental – psychiatric- disorders.Multiaxial System for diagnosis Axis I: Psychiatric disorders (clinical diagnosis) Axis II: Personality disorders + Mentalretardation Axis III: Medical & Physical disorders Axis IV: Social stress Axis V: Global assessment of Function.
International Classification of Diseases and Related Health Problems – 10th editionDeveloped by the WHOThis system includes diagnoses of all the organsystems in the human body, not just mentaldisorders, therefore allowing full diagnosis ofpatients.Multiaxial System for diagnosis Axis I: Clinical Diagnosis Axis II: Social Disabilities Axis III: GAF
DepressionMajor depressive disorderis a mental disordercharacterized by an all-encompassing low moodaccompanied by low self-esteem, and loss ofinterest or pleasure innormally enjoyable activities.
Epidemiology1. Incidence 3-7% of the population2. Life time prevalence 10-20%3. Female : male is 2:14. Strongly associated with medical diseases up to 30-50%
Clinical Picture: I- Psychological symptoms: b. Depressed mood and sadness (diurnal variation; more severe in the morning) c. Loss of interest d. Hopelessness, helplessness, self depreciation and guilt, death wishes, suicidal thoughts. e. Psychotic symptoms: delusions or hallucination (mood congruent)
II- Physiological Symptoms:a. Decreased appetite, fatigue and loss of energyb. Weight loss and digestive upsetc. Sleep disturbance; insomnia, early morning awakening, interrupted sleep… etcd. Loss of libido.
IV- Motor, cognitive symptoms:a. Difficulty attention and concentration.b. Slow thinkingc. Psychomotor retardation or agitation.V-Impaired social and occupational functioning.
The DSM-IV-TR recognizes five further subtypes ofMDD, called specifiers, in addition to noting thelength, severity and presence of psychotic features:I-Melancholic depression:is characterized by a loss of pleasure in most or all activities, afailure of reactivity to pleasurable stimuli, a quality ofdepressed mood more pronounced than that of grief or loss, aworsening of symptoms in the morning hours, early morningwaking, psychomotor retardation, excessive weight loss (notto be confused with anorexia nervosa), or excessive guilt.
II-Atypical depression:is characterized by mood reactivity (paradoxicalanhedonia) and positivity, significant weight gain orincreased appetite (comfort eating), excessive sleepor sleepiness (hypersomnia), a sensation of heavinessin limbs known as leaden paralysis, and significantsocial impairment as a consequence ofhypersensitivity to perceived interpersonal rejection.
III-Catatonic depression:is a rare and severe form of major depressioninvolving disturbances of motor behaviorand other symptoms. Here the person is muteand almost stupor, and either remainsimmobile or exhibits purposeless or evenbizarre movements.
IV-Postpartum depression:(Mild mental and behavioral disorders associatedwith the puerperium, not elsewhere classified inICD-10) refers to the intense, sustained andsometimes disabling depression experienced bywomen after giving birth. Postpartum depression,which has incidence rate of 10–15% among newmothers, typically sets in within three months oflabor, and lasts as long as three months.
V-Seasonal affective disorder(SAD):is a form of depression in which depressiveepisodes come on in the autumn or winter,and resolve in spring. The diagnosis is madeif at least two episodes have occurred incolder months with none at other times,over a two-year period or longer
Course and prognosis:1. Depression is a recurrent disorder in 50% of cases.2. Suicide risk is as high as 15% in severe cases,3. Mild cases need minimal intervention4. Individual episodes is generally good
AnxietyAnxiety is a psychological and physiological state characterizedby cognitive, somatic, emotional, and behavioral components.These components combine to create an unpleasant feeling that istypically associated with uneasiness, fear, or worry.Anxiety is a generalized moodcondition that occurs withoutan identifiable triggering stimulus.
Generalized Anxiety Disorder:It is the subjective sense of fear or apprehensionwithout objective reasoning. It is accompanied byAutonomic manifestations and physical discomfort.Epidemiology:LTP: 5-6% of the populationAge: 20-40 but can affect any ageGender: equal in both maleand female.
Etiology:1.Genetic Factors.2.Neurotransmitter; monoamines (NE, 5HT), Inhibitory NT (GABA)3.Anatomical; locus ceruleus, amygdala.4.Psychosocial aspect; cognitive, social learning, psychoanalytical5.Stress diathesis model; activity of HPA axis in biologically predisposed person when subjected to stress
A. Psychological Symptoms.B. Cognitive Symptoms.Deferential Diagnosis: ◦ Normal anxiety; less severe, shorter duration, for objective reason, with adaptive response and increasing performance. ◦ Medical diseases: hyperthyroidism, cardiovascular, respiratory (COAD), head injury, parkinsonism….etc.
¬ Psychiatric Disorders: phobia, OCD,Social anxiety, Substance use disorder,adjustment disorder.Course and prognosis:GAD has chronic course, often comorbidities; panicand depression.
Panic DisorderAttacks of discrete period of intense fear occurringover a short time develop abruptly and reach apeak within 10 min.. It is unexpected, recurrentattack that is not related to specific situation.Epidemiology:LTP: 2-3%Age: usually young age before 30sSex: Female > males.
Clinical picture:B. Panic attack:Attack is associated with at least 4 of the followingsymptoms: a) Cardiovascular system; palpitation, pounding heart….etc b) Respiratory system; shortness of breath, feeling of chocking… etc c) GIT symptoms; nausea, abdominal discomfort. d) Center nervous system; feeing dizzy, shaking, numbness ….etc) e) Derealization and depersonalization. f) Autonomic overactivity.
A. Anticipatory anxiety:In between attacks, persistent concern abouthaving another attack.C. Agoraphobia:Fearing of going to places where escape might bedifficult.Phobic avoidance: with no treatment patientmay develop avoidance with impairment offunctions.
Obsessive CompulsiveDisorderUndesired, irrational subjective experiences ofobsessions or compulsions.Unwanted thought, urges or actions.Uncontrolled (patient tries to resist). Picture 2Unacceptable.Epidemiology:LTP:2-3%Age of onset: 15-25 yrs.Sex: equal in both sexes.
Clinical picture:: Obsessions: intrusive persistent unacceptable own ideas.t Compulsions: repetitive voluntary act to relief anxiety; motor or mental acts.r Anxiety: marked distress due to both obsessions and compulsions.Course and Prognosis:20-30%; significant improvement40-50%; moderate improvement.20-30%; no improvement
Post-traumatic stress disorderis an anxiety disorder which results from a traumaticexperience, an extreme situation, such as combat, rape,hostage situations, or even serious accident.It can also result from long term (chronic) exposure to asevere stressor, but cannot cope with continuous combat.c.Flashbacks,d.Avoidant behaviors,e.Depression.