Anxiety & Psychosomatic Disorders (RAKCON Lecture) PDF

Anxiety & Psychosomatic (or Stress- Related) Disorders Welcome to the third talk of lecture series on Clinical Psychiatry for B.Sc. Nursing students. Exactly 1 week since 2nd session (26.09.2024). SS by Swarndeep Singh (3.10.2024)  Dr. Swarndeep Singh MBBS (AIIMS, Delhi)...

Anxiety & Psychosomatic (or Stress- Related) Disorders Welcome to the third talk of lecture series on Clinical Psychiatry for B.Sc. Nursing students. Exactly 1 week since 2nd session (26.09.2024). SS by Swarndeep Singh (3.10.2024)  Dr. Swarndeep Singh MBBS (AIIMS, Delhi); MD (AIIMS, Delhi) Completed Leadership Development Program (Leading for Innovation in Healthcare – India) from University of Warwick, UK (2021) Honorary Consultant for National Certificate Course in Common Mental Disorders for training primary care physicians by Public Health Foundation of India (2022) Certified QPR suicide prevention gatekeeper instructor, QPR Institute, USA Awards: Dr Satyanand Gold Medal (Psychiatry, AIIMS); Dr Anil Malhotra Award for best paper in drug addiction; Travel Grant Award for 3rd International Brain Current Stimulation Conference; Dr BB Sethi Award for best designation: Assistant poster paper >100 Publications in National & International Journals; Professor, Co-authored 10 book chapters; Academic editor: 2 Dept. of journals Areas of Interest: Interventional Psychiatry, Digital Psychiatry, Psychiatry, Suicide Prevention, C-L Psychiatry, Academic VMMC & Psychiatry Safdarjung OVERVIEW Anxiety disorders Generalized anxiety disorder Social anxiety disorder Phobias Obsessive Compulsive Disorder (OCD) Panic disorder with or without Agoraphobia Psychosomatic (or Stress-related) disorders Bodily distress disorder Dissociative disorders Post-traumatic Stress Disorder (PTSD) Sexual disorders Sleep disorders Headache Anxiety Disorders Case Study 1 Mr. D, 34 years old man plays harmonium extremely well. He had been playing it at home and in small groups, since the age of 12. When he was 16years old, his school teacher prompted him to participate in public show of music at his school. He agreed on great persuasion. But as he went in the middle of the audience, he started sweating and his mouth went dry. He was dumbstruck and he could not play a note. He felt that people will laugh at him if he is unable to play well. So he stepped back. He attempted such performances 2-3 times later but he failed. He also started getting the feeling that people will make Why do fun of think, you him if hean stood in front extremely goodofmusician them. He could could not not perform perform well in in well histhe career and could not do well till show? date. How has his thoughts of people and society potentially impacted his life?  Anxiety disorders refer to a group of mental disorders characterized by feelings of worry and fear (real &/or perceived) including Generalized Anxiety Disorder (GAD) Panic disorder Phobias Social anxiety disorder Obsessive-compulsive disorder (OCD) Post-Traumatic Stress disorder (PTSD) More of a chronic than a transient disorder. Important points: Comorbidity is frequent: depression, substance use disorder, personality disorder Presentation: Often with physical symptoms Management: Depression and Other Common Mental Requires Disorders Global Health Estimates WHO/MSD/MER/2017.2 World Health Organization 2017 pharmacological or psychological Prevalence of Anxiety Disorders Prevalence of anxiety disorders- 3.6% (264 million globally) Anxiety disorders are more common among females than males (4.6% compared to 2.6% at the global level) Prevalence rates do not vary substantially between age groups, although there is an observable trend towards India- Prevalence of 3.0%lower prevalence (Around among 38 million older ageliving people groups with anxiety) Anxiety disorders very commonly co-occur with depression and also with substance use disorders Generalized Anxiety Disorder (GAD) General apprehension Motor tension (i.e. ‘free-floating restlessness, anxiety’) or excessive inability to relax, worry focused on trembling) multiple everyday events, most often concerning family, Anxiety - health, finances, and generalized and school or work (worries persistent for at about future Subjective experience least several misfortunes, feeling " Autonomic over months Nervousness, on edge", etc) activity difficulty light-headedness, maintaining sweating, concentration, tachycardia, irritability, or tachypnea, dry sleep disturbance Significant distress or impairment in personal, family, social, mouth educational, occupational, or other important areas of functioning. Panic Disorder [Episodic Paroxysmal Anxiety] Recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances. Unpredictable Dominant symptoms - sudden onset of palpitations or increased heart rate, sweating, trembling, shortness of breath, chest pain, dizziness or lightheadedness, chills, hot flushes, fear of imminent death chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization) Secondary fear of dying, losing control, … Significant impairment in personal, family, social, educational, occupational, or other important areas of functioning Agoraphobia Conceptualized as marked & excessive fear or anxiety that occurs in, or in anticipation of, multiple situations where escape might be difficult or help not available; such as using public transportation, being in crowds, being outside the home alone (e.g., in shops, theatres, standing in line) Fear of specific negative outcomes (e.g., panic attacks, other incapacitating or embarrassing physical symptoms) in these situations Active avoidance behaviours; Minimal symptoms often in the presence of a trusted companion (Agoraphobics’ Companion) Phobic Anxiety Disorder A group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread. Phobic anxiety and depression often coexist. Examples of phobia-related disorders: Hydrophobia, Acrophobia, Claustrophobia, etc. Social Anxiety Disorder Marked and excessive fear or anxiety that consistently occurs in one or more social situations such as:  social interactions (e.g., having a conversation)  being observed (e.g., eating or drinking),  performing in front of others (e.g., giving a speech) The social situations are consistently avoided or else endured with intense fear or anxiety. Symptoms persist for at least several months and are sufficiently severe to result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Obsessive Compulsive Disorder (OCD) Obsession: repetitive and persistent thoughts (e.g., of contamination), images (e.g., of violent scenes), or impulses/urges (e.g., to stab someone) that are experienced as intrusive and unwanted, and are commonly associated with anxiety. A person typically attempts to ignore or suppress them or neutralize them by performing compulsions. Compulsion: repetitive behaviors or rituals (e.g. washing, checking), including repetitive mental acts (e.g. mentally repeating specific phrases), that the individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of ‘completeness’. They are either not connected in a realistic way to the feared event (e.g., arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (e.g., showering daily for hours to prevent illness). OCD: Obsession(s) with or without compulsion(s) are time-consuming (e.g., > 1 hour/day) or result in significant distress or impairment/ dysfunction ASSESSMENT OF ANXIETY DISORDERS Does the patient have any of the following symptoms? 1. Restlessness 2. Palpitations 3. Dryness of mouth 4. Indigestion 5. Numbness or Tingling 6. Dizzy or lightheaded 7. Heart Racing 8. Feeling of Choking 9. Hands Trembling 10.Difficulty in Breathing Yes Is there any medical history likely to explain above symptoms? Treat the No medical Yes condition Anxiety disorder likely Are the symptoms generalised and present most of the times during the day? Yes No (Episodic events) Is there a history of prior traumatic event and flashbacks? Are the symptoms triggered by any repetitive thought impulse or image Yes No (Obsession)? Does any particular behaviour reduces these Consider Post Consider thoughts and symptoms traumatic Generalised (Compulsion)? Stress Anxiety Yes No Disorder Disorder Consider Obsessive (Contd.) Compulsive Disorder  Are the symptoms triggered by exposure to any particular situation or objects? No Yes On exposure to social On exposure to Consider Panic Disorder situation? situations other than Consider Social social Anxiety disorder e.g. Height, closed spaces, animals etc. Consider Specific Phobia Case study 2 Mr. E, a 26 years old male, was working as driver of a private taxi. From the age of 19years, he started having complaints of sudden feeling of restlessness, racing heart and shortness of breath without any precipitating event. He would feel that he’s having a “heart attack”. This would get aggravated for 10-15 minutes in episodes however he would remain restless most of the times in a day. He visited several physicians multiple times and got his ECG done. It would however reveal no abnormalities. The symptoms had a significant impact on his work and he stopped going to work. To one of the doctors, on enquiry, he revealed that he would feel worried most of the times, and feel that something is going to happen to him. Does Mr. E have any mental health problem? Management: Overview Management: Psychoeducation Anxiety disorders are:  Common  Chronic (may have waxing & waning course)  Distressing and disabling Anxiety disorder is a psychological problem and not physical (but it may manifest with both psychological & physical symptoms) Substance use may aggravate symptoms and hence maintain abstinence/ decrease use Continuing chronic stress may also aggravate symptoms Numerous treatment options are available - therapies,medicines and self-help Physical exercise has a benefit as a part general good health Disorder Management Generalised Long term management: anxiety disorder Pharmacotherapy with SSRI (e.g. escitalopram, sertraline, etc.) + Cognitive Behaviour Therapy (CBT, If feasible); Short term management: Benzodiazepines (BZDs) for acute control of anxiety symptoms; Problem solving Panic disorder Pharmacotherapy with SSRI's, beta blockers; CBT involving relaxation training and cognitive remodelling; BZD (mouth dissolving) SOS use for aborting an attack Phobic anxiety Pharmacotherapy with SSRI's, beta disorder blockers (performance anxiety); CBT Clinical Point: (systematic desensitisation) SSRIs may paradoxically increase anxiety initially or induce akathisia that mimic restlessness of anxiety in some; So, start at lower doses and up titrate less rapidly than that for depression Medications SSRI Preferred choice for anxiety disorders. Should be continued for at least 6 months after optimal dose is reached after which the dose can be tapered As explained in depression SNRI Venlafaxine, generally used in anxiety disorders TCA Clomipramine is used in treatment of OCD apart from fluoxetine and fluvoxamine Clinical Practice Points: In anxiety, required medicine should be started at lower dose first (as compared to depression) and then dose should be slowly increased Commonly prescribed SSRIs: Escitalopram (5-20 mg/day), Sertraline (50-200 mg/day) Behavioural techniques/ Yoga Instructions before exercise Follow fixed timings for exercise (Around 2-3 times a day) Choose a quiet place (where nobody can disturb), with pleasant temperature No exercise if hungry or have heaviness after a meal Wear comfortable clothes Do not worry about how it goes and whether you can relax successfully Try to breathe through your nose and completely fill your lungs Breathe deeply, slowly and regularly Record after each exercise, how much you could relax (by rating Deep Breathing Relaxation Video: https://youtu.be/tEmt1Znux58 Progressive Muscle Relaxation Tighten muscle (Inhale: Feel anxiety and effort in the muscle) Relax muscle (Exhale: Feel the relaxed muscle) Go to tighten the next muscle Psychosomatic Disorders Psychosomatic Disorders Greek word “psyche” (mind) and “soma” (body). Mental health, Disorder s Here for conventional purpose we have explained Complex disorders that commonly interplay present with intersection Psychoso matic of mind and bodily Environ Disorders Bodily symptoms mental consequ and ences Social and Disorders of Bodily influenc sympto distress es ms Dissociative disorders Sexual disorders Sleep disorders Headache Case Study 3rs. A, a 40 year old M married woman, came to OPD with complaints of stomach ache since last 2 years. This pain would be dull aching, with variable location every time. There was no specific diurnal variation or relation to meals status. Occasionally she would also have dull aching lower backache independent of her menstrual cycle phase. There was no history of vomiting or indigestion. However these complaints had led to slight decrease in her appetite. She visited multiple doctors, got her blood tests, abdominal ultrasound and gynecological examination done, but they revealed no abnormality. She had growing worries about her physical symptoms and her work at home hampered because of this. With progression of days her concerns increased and her visits to multiple doctors increased. She would sleep well at night but faced daytime trouble with these symptoms. She lived in her house with her husband who would be out for job in a stretch of 4 months and two middle school going children. She also had her mother-in- law at her home who would criticize her for not working well at home. She would also blame A’s parents for unnecessary reasons and make her feel miserable. Mrs A, being a docile and quiet woman by nature would never answer her back and tried to do maximum possible for her. She had stopped going to her neighbours for the fear of her mother-in-law. She would feel helpless in absence of her husband and would insist on him coming What backenquiry focused home, would which was you in make in vain. Mrs. A case? How important is psychological assessment of Mrs. A in the face of her normal physical tests? Bodily Distress Disorder presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms, which may be manifest by repeated contact with health care providers Includes “Somatoform” group of disorders Medical symptom/ Pain +/- Degree of attention is Excessive attention is clearly excessive in not alleviated by relation to its nature appropriate clinical and progression examination and investigations and appropriate reassurance Bodily symptoms and associated distress are persistent being present on most days for at least several months associated with significant impairment in personal, family, social, educational, occupational or other important areas of functioning Assessmen tCOMMON PRESENTATIONS OF OTHER SIGNIFICANT MENTAL HEALTH COMPLAINTS Feeling extremely tired, depressed, irritated, anxious or stressed. Somatic complaints for longer time and larger intensity (degree of attention is clearly excessive) Is there a physical cause that fully explains the presenting symptoms? Yes No Is this depression or another mental health Manage any condition? E.g., Anxiety disorder, mood physical cause disorder, Substance Use identified and recheck to see if the symptoms Yes No persist Mx. As per the diagnosis Is the person seeking help to relieve symptoms or having considerable difficulty with daily functioning because of their symptoms? No Yes No treatment needed Psychosomatic disorder- Bodily distress disorder or Disorder associated with Stress likely Has the person been exposed to extreme stressors? (e.g. physical or sexual violence, major accidents, bereavement or other major losses) Yes Go to Guidelines 1 and 2 No Go to Guidelines 1 IF THERE IS IMMINENT RISK OF SUICIDE, ASSESS AND MANAGE that before continuing to Guidelines 1 and 2.  Guidelines 1 Other Significant Mental Health Complaints (With no subjectively perceived extreme stressors) Psychoeducation and Counselling Addressing physical concerns- Acknowledge the symptoms and provide possible explanations Inform the person that clinical examination and investigations do not reveal disorder that is as serious/concerning as perceived by the patient Reduce unrealistic expectations by patients if they insist on ordering unnecessary lab investigations Clinical Tip- DO NOT give vitamin injections or other ineffective treatments (unless advised by a psychiatrist) Psychoeducation and Counselling Addressing psychosocial stressors- Interventions Acknowledge importance Encourage continuation of of addressing symptoms daily routine activities & Ask for their own work explanation of the cause Take proper steps to reduce about their concerns stress Ask Explain- Sleep hygiene Physical activity Emotional Adequate diet suffering/stress may Meditation/ Yoga involve the experience of Psychosocial support bodily sensations- stomach aches, muscle tension, etc. OR may aggravate the pre- Guidelines 2 Other Significant Mental Health Complaints in People Exposed to Extreme Stressors (e.g. physical or sexual violence, major accidents, bereavement or other major loss) In addition to prior guidelines Address the following- Person’s concerns and emotional set-backs Protection from harm (in case of suicidal ideas) Need for social and psychological support (connecting to friends and family and others Return to previous, normal activities (if it is feasible and culturally appropriate) Psychological Clinical tip- Counselling and Suspect post-traumatic stress disorder (PTSD) if- Following Interventions: Symptoms +: considerable difficulty with daily Give regards to the persons functioning for at least 1 feelings, empathize and provide month and include recurring support frightening dreams, flashbacks or intrusive Explain about loss, its psychological memories of the events and physical impact accompanied by intense fear or horror; deliberate Explain how they get better with avoidance of reminders of the time event; excessive concern and alertness to danger or Explain need of socializing and reacting strongly to loud trying to carry out routine activities noises or unexpected movements. Follow Up RECOMMENDATION ON ASSESS FOR IMPROVEMENT FREQ. OF CONTACT: Is the person reporting Ask the person to return improvement in in symptoms? 2-4 weeks if their symptoms do not improve or if, at any Yes No time, their symptoms worsen. Continue with treatment If the person is not improving or the plan person or » Follow-up as needed the caregiver insists on further investigations and treatment: » Review Guidelines 1 and 2 » Consider consulting a Psychiatrist. Dissociative Disorders involuntary disruption or discontinuity in the normal integration of memories, thoughts, identity, affects, sensations, perceptions, behavior, or control over bodily movements thoughts Presentation of mood Neurologic Integration al perceptions symptoms Amnesia , memories etc. behavior seizures or convulsions, weakness or paralysis, alteration of sensation, symptoms of movement disorder, symptoms of gait disorder, cognitive symptoms, alteration of consciousness, visual symptoms, auditory symptoms, dizziness, and Case study 4 Mr. B, 30 years old male, working as laundry man, presented with complaints of recurrent episodes of sudden tonic-clonic contractions of all the four limbs. These contractions of are coarse in nature, associated with fall, but no injuries sustained during any falls. These episodes usually last for 30-40 minutes, often start after fights with wife. Episodes usually terminate after sprinkling water of his face. What further questions will be to determine nature of these episodes? Assessment Dissociative Disorders Obtain detailed physical history Study/ Review all prior investigations Exclude organic disease Reassure caregivers about physical signs Identify psychosocial stressors Evaluate for co-morbid mental disorder and suicide risk Management (Dissociative Disorders) 1. General advice- Lifestyle changes Relaxation 2. Occupational and social: Occupational counselling Problem-solving for social problems 3. Psychological management Refer to specialists 4. Regular follow-up appointments at fixed, pre-arranged intervals with goals set for each visit 5. Minimize use of drugs Resources Expand your knowledge with these valuable resources on mood dis WHO Mental Health Gap Action Programme (mhGAP) guideline Good starting resource for learning management of mental, neurological and substance use disord Psychiatry and/or Nursing Textbooks Kaplan & Sadock’s Synopsis of Psychiatry (12th edition) Psychiatric mental health nursing: concepts of care in evidence-based practice Online Resources Next Gen Guru – Gemini ; ChatGPT; ∞ Continuing Education Workshops and courses to enhance your mental health assessment skills.  Thank You “Stay Hungry. Stay Foolish.” Questions? Feedback Contact Feel free to ask about Share your thoughts on Email: any aspect of the topic. the lecture and suggest swarndeepaiims@gmail. topics for future com sessions. Medication Doses Side-effects Caution Clonazepa Start with 0.25mg/d Sedation, Overdose- respiratory m Titrate up to 1mg in fatigue, depression divided doses by 3 forgetfulness, Sudden withdrawal from days confusion(at higher doses – Maximum dose higher doses) precipitation of seizures 4mg/d * Stop use in 6-8 weeks- causes dependence Venlafaxin Start with 37.5mg/d Headache, Can cause- Dose e Titrate by 75mg nervousness, dependent increase in every 4 days until sedation, sexual blood pressure desired efficacy is dysfunction, Can induce switch to reached hyponatremia, hypomania in bipolar Maximum dose Nausea, disorder 375mg/d * diarrhea, Rarely- activation of decreased suicidal ideation appetite Clomipram Start with 25mg/d Anti-cholinergic- Orthostatic hypotension ine Titrate to 100mg blurred vision, common- routine over 2 weeks constipation, dry monitoring required Maximum dose mouth Rarely- QTc prolongation, 250mg/d * Fatigue, lowering seizure dizziness, threshold *Though these are maximum approved doses, psychiatric sedation, consult Induction should be of mania sought while prescribing doses higher than 2 mg/d for Clonazepam, 225 headache, mg/d for Venlafaxine, 150 mg/d forSexual Clomipramine dysfunction Important Tips for Benzodiazepine Use in Anxiety Doctors should consider the following while prescribing BZDs for anxiety: A short-term, scheduled dosing course of BZDs with the lowest possible dose & for pre-defined treatment duration in discussion with the patient at onset of treatment BZDs should be tapered gradually over the course of 1-2 weeks, to reduce the risk of withdrawal or rebound symptoms Avoid prescribing BZDs for long-term management due to the risk of developing BZD dependence Be cautious in prescribing BZDs to addiction-prone patients or in patients with compromised respiratory function Long-acting BZD (e.g. diazepam) preferred when a hypnotic effect is needed at night & an anxiolytic effect is required during the daytime Shorter-acting BZD (e.g. alprazolam, etizolam) preferred BZD use related cautions (contd.): Advise patients taking benzodiazepines, not to drive or operate heavy machinery due to risk of drowsiness & accidents Using BZD with other CNS depressants such as alcohol can cause excessive sedation (even respiratory depression) Long term use of BZD might lead to impairments in cognitive functioning and memory (Disturbed new learning by association, State dependent learning, etc.) BZDs may produce disinhibited behavior and paradoxical worsening of anxiety and agitation in some people (esp. elderly or pediatric patients) erview- General guidelines for Bodily Distress disor Assessment Management Follow-Up Rule out physical 1. Other significant causes that would fully mental health explain the intensity and complaints concern of presenting symptoms 2. Other significant Rule out depression or mental health other mental health complaints in conditions people exposed to Assess if the person is extreme stressors seeking help to relieve symptoms or has considerable difficulty with daily functioning Assess if the person has been exposed to extreme stressors