Common Psychiatric
Problems In PHC
Done by;
ZAID ALMUBARAK
YAZEED 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
The causative are multifactorial
GENETIC
FACTORS
BIOLOGICAL
Reduced level of
.NE,5HT, &DA
As supported by family
and twin studies
PSYCHOLOGICAL
Stressful events.
Premorbid personality
factors.
Cognitive distortions
Classifications of
Depression
According to the DSM Classification :
o
Major Depressive Disorder.
Dysthymic Disorder (Chronic Depression).
Postpartum Depressive Disorder.
Seasonal Depressive Disorder (Usually in Winter)
Unspecified Depressive Disorder
Clinical Features
Mood Changes :
A.
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.
Biological Features :
C.
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.
Cognitive Features (Thinking):
D.
1.
Poor Attention, Concentration and Memory.
2.
Remembering Negative Memories, Feeling Guilty, Not
Seeing a Future and Negative Thinking of the Present.
Psychotic Features :
E.
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
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
Not
impairment in functioning.
due to substance abuse , a medication or a medical condition
(e.g., hypothyroidism).
DYSTHYMIC DISORDER
Diagnostic 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.
2.
3.
Danger to self
Danger to others
Total inability to function
4.
Drug resistance cases
5.
Observation and
clarify Diagnosis
Full clinical response in 6-8 weeks in major depression disorder.
SSRI
Uses:
Depressive disorders.
Anxiety
phobia
panic disorders.
Obsessive compulsive disorder.
Premature ejaculation.
S/E
Headache
Nausea
Stomach ache
Decrease libido
Wight gain
Sedation
TCA
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
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 & signs
Features 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:
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.
E.
The anxiety and worry are associated with 3of 6
Restlessness
easily fatigued.
Difficulity concentrating.
Irritability
muscle tension
Sleep disturbance.
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
persons 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 didnt 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
disorder
Hypochondriasis
Body
dysmorphic disorder.
Conversion
Pain
disorder
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 symptoms
headache, chest pain, abdominal pain, back pain, joint pain,
painful urination (dysuria), painful sexual intercourse and
painful menstruation (dysmenorrhea).
GI symptoms
nausea, vomiting, difficulty in swallowing and diarrhea
Cardiopulmonary symptoms
shortness of breath (dyspnea), and palpitation.
Other symptoms
dizziness, 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
Hypochondriasis
People 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
counselors 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. AlKhathami, 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-ofDepression-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-ofDepression-in-The-Middle-East-Alarming-/ )
