Understanding Anxiety and Depression

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Understanding Anxiety-Depression

• Dr Douglas Kong
• Retired Psychiatrist
• Executive/Business and Life Coach

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What do you mean?

• A man who lost money on the stock market
• I am depressed I lost some money!
• A lady who could not buy her favourite dresses
  due to no stock
• I am depressed I cannot get what I want!
• A patient who just saw his psychiatrist
• I am so depressed, I just want to go and kill
  myself!

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The word depression can mean

• A feeling of frustration (layman)
• A Mood State
• A Syndrome
• An illness

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STRESS
SEPARATIONAMBIVALENCE
LOSS
ANXIETY
DEPRESSION
UNDERLYING BIOLOGICAL VULNERABILITIES
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Two types of Anxiety Disorders1) Generalized
Anxiety Disorder(GAD)2) Panic Anxiety Disorder
(PAD)
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Causes of Anxiety

• Generalized anxiety is caused by negative thought
  or worry
• Psychological type anxiety
• Panic anxiety is due to the sudden activation of
  the stress response
• Biological type of anxiety

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Definition of Generalized Anxiety

• A condition characterized by 6 months or more of
  chronic, exaggerated worry and tension
• that is unfounded or much more severe than the
  normal anxiety most people experience
• People with GAD usually expect the worst
• They worry excessively about money, health,
  family, or work, even when there are no signs of
  trouble
• They are unable to relax and often suffer from
  insomnia
• Sometimes the source of the worry is hard to
  pinpoint
• Simply the thought of getting through the day
  provokes anxiety

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Definition of Panic Anxiety

• An anxiety disorder that is characterized by
  sudden attacks of fear and panic. 
• Panic attacks may occur without a known reason,
  but more frequently they are triggered by
  fear-producing events or thoughts, such as taking
  an elevator or driving
• Symptoms of panic attacks include rapid
  heartbeat, strange chest sensations, shortness of
  breath, dizziness, tingling, and anxiousness
• Hyperventilation, agitation, and withdrawal are
  common results
• Panic disorder is due to an abnormal activation
  of the body's hormonal system, causing a sudden
  'fight or flight' response

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Symptoms of Generalized Anxiety

• Feelings of panic, fear, and uneasiness
• Problems sleeping
• Cold or sweaty hands and/or feet
• Shortness of breath
• An inability to be still and calm

• Heart palpitations
• Dry mouth
• Numbness or tingling in the hands or feet
• Nausea
• Muscle tension
• Dizziness

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The many facets of anxiety

• Nature of anxiety has many components
• Cognitive component worry, fears and
  anticipation
• Emotional component stress, anxiety, fears
• Physiological component arousal, tension
• Behavioral component- attentional focus,
  flight/fight

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Physical Symptoms May Predominate in GAD

• Aches, pains, soreness
• Insomnia (difficulty falling asleep)
• Symptoms of autonomic arousal
• Tachycardia, palpitations, sweating, tremor
• Gastrointestinal symptoms
• Nausea, diarrhea
• Other
• Dizziness, light-headedness
• Breathing difficulties
• Numbness, tingling
• Hot or cold flushes

Starcevic. Anxiety Disorder in Adults. Oxford
University Press. 2005102-140 Gorman. Clin
Cornerstone. 20013(3)37-43
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The nature of panic attacks

• Activation of the stress response
• Not warranted by context
• Intense fear/anxiety is extremely unpleasant
• Peaks with 10 minutes and last for up to 20-30
  minutes
• Produce foreboding of illness, madness, collapse,
  dying
• Leads to anticipation when attack is over
• Often gets progressively worse march of panic

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Symptoms of panic

• Comes without warning sometimes with no apparent
  cause
• Intense anxiety, fear and threat
• Palpitation, heart pounding rapidly
• Shortness of breath
• Sweating
• Trembling
• Hot flushes, chills
• Choking sensation
• Chest pain or discomfort
• Nausea
• Dryness of mouth

• Feeling of dread
• Fear of dying
• Fear of going mad
• Ringing in your ear
• Tingling sensation at your fingertips
• Dizziness
• Feeling faint
• Numbness, pins and needles
• Shivering
• Shaking
• Stomach churning
• Urgency need to go to toilet

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Anxiety Symptoms Prevalence Estimates in the
General Population
Prevalence (n9282) Prevalence (n9282) Prevalence (n9282)
Duration of anxiety symptoms (minimum) Point (current) 1-year Lifetime
1 month 2.6 5.5 12.7
3 months 2.1 3.9 8.0
6 months (DSM-IV GAD) 1.8 2.9 6.1
12 months (DSM-IV GAD) 1.6 2.2 4.2
Anxiety symptoms fulfilling DSM-IV criteria for
GAD, except for duration Data from NCS-R (DSM-IV
criteria), USA Kessler et al. Psychological Med.
2005351073-1082.
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GAD Lifetime Prevalence in the General Population
Data from surveys in 4 countries (DSM-III-R
criteria) Kessler et al. Psychol Med.
2002321213-1225
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The Autonomic System
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Control of the autonomic nervous system
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Regulation of the hypothalamus
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Depression A Systemic Illness

• Emotional1
• Depressed mood
• Anhedonia
• Hopelessness
• Low self-esteem
• Impaired memory
• Difficulty concentrating
• Anxiety
• Anger/irritability
• Suicidal ideation

• Somatic2
• Headache
• Fatigue
• Disturbed sleep
• Dizziness
• Painful physical symptoms
• Gastrointestinal (GI) complaints
• Sexual dysfunction
• Menstrual problems

1. DSM-IV-TR. Washington, DC American
Psychiatric Association 2000349-356.
2. Kroenke K, et al. Arch Fam Med.
19943774-779.
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Multiple Somatic Symptoms May Be Associated With
Depression
Somatic symptoms included the following

• Fatigue
• Insomnia
• Menstrual problems
• Dizziness
• GI complaints
• Headache
• Joint or limb pain
• Back pain
• Abdominal pain
• Chest pain
• Sexual dysfunction

0 to 1 (n215)
2 to 3 (n225)
4 to 5 (n191)
6 to 8 (n230)
?9 (n139)
Kroenke K, et al. Arch Fam Med. 19943774-779.
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Depression Is More Common in Women
Odds Ratio (95 Confidence Interval) for Major
Depressive Disorder (MDD) in Women vs. Men 1.7
(1.52.0)1

21.3
12.7
Lifetime prevalence of MDD ()2
Women
Men

• N8,0982
• Plt0.05.
• Data from the National Comorbidity Survey, a
  large population-based epidemiologic study
  (N8,098), 1990-1992.
• 1. Kessler RC, et al. JAMA. 20032893095-3105.
• 2. Kessler RC, et al. J Affect Disord.
  19932985-96.

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Subtypes of Depression

• Melancholia poor predictor of response,
  correspond to Bipolar Depression Type II
• Atypical poor response to TCA but good response
  to SSRIs or MAOIs. Bear similarities to PTSD and
  Borderline Disorders

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Implications of comorbid depression and anxiety
Poorer response to treatment
Greater symptom severity
Increased use of health care resources
Greater occupational impairment
Increased incidence of suicide
Greater functional impairment
Increased burden on society
More chronic course of illness
Kessler et al. Arch Gen Psychiatry 1994 51
8-19. Lecrubier. J Clin Psychiatry 1998 59
(Suppl 8) 11-14. Lecrubier. J Clin Psychiatry
1998 59 (Suppl 17) 33-37. Kaufman Charney.
Depress Anxiety 2000 12 (Suppl 1) 69-76.
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Depression and Neurodegeneration Hippocampal
volume and duration of depressive episode
5800
R2 0.36 p 0.002
5300
4800
Hippocampal volume ( mm3)
4300
3800
3300
2800
0
1000
1500
2000
2500
3000
3500
4000
500
Episode Duration (days)
Sheline et al. J. Neuroscience 1999
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Stress and Cell Death
STRESS
Glucocorticoids
Dendritic branching
BDNF
Atrophy/death of neurons
Normal survival and growth
BDNFbrain-derived neurotrophic factor.Sapolsky
RM. Arch Gen Psychiatry. 200057925-935. Duman
RS, et al. Biol Psychiatry. 200048732-739.
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Potential Neuroanatomic Substrates of Depression
Cingulate cortex
Hippocampus
Amygdala
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Biochemistry of Depression

• From the action of different types of
  antidepressants, monoamines deficit in the brain
• Noradrenaline was considered important because of
  1st generation of tricyclic antidepressants(TCAs)
  
• Serotonin replaced Noradrenaline as better
  antidepressants were SSRIs (Specific Serotonin
  Reuptake Inhibitor)
• Reduced level of metabolites of SSRIs in
  post-mortem of suicides of depressed patients
• Dopamine was also implicated as some
  antidepressants block dopamine receptors

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Disruption of sleep-wake cycle

• Agomelatin, an analogue of Melatonin is an
  antidepressant
• It stimulates a melatoninergic receptor
• Other factors to do with sleep appear to
  influence depression
• Sunlight and exercise appears to have positive
  effect on depression
• Improvement of depression restores sleep pattern

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Introduction

• Approximately 10 to 15 percent of patients
  seeking treatment in primary care clinics had
  depression
• More depressed patients are seen by primary
  care doctors than by actual psychiatrists1
• Majority of them were not diagnosed
• Most of the diagnosed were not receiving
  appropriate treatment
• From iceberg phenomena to reverse iceberg
  phenomena

• 1. Watts CAH. Depressive Disorder In The
  Community. BristolJohn Wright and Sons. 1966

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Undefined burden of depression

• Lost of production from premature deaths cause by
  suicide
• Lost of production from lost of work
• Lost productivity from family members caring for
  depress patients
• Reduced productivity from depress patients while
  at work
• Poor cognitive development in children of
  mentally ill parents
• Emotional burden and decrease quality of life of
  the carers
• Direct or indirect financial cost for families
• Cost of accidents by those who are depress,
  especially drivers, pilots and factory workers

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From The Epidemiology of Major Depressive
Disorder Results From the National Comorbidity
Survey Replication (NCS-R)
JAMA. 2003289(23)3095-3105. doi10.1001/jama.289
.23.3095
Figure Legend
?23 290.1, Plt.001for all. Analysis used
weighted data.
Date of download 7/24/2015
Copyright 2015 American Medical Association.
All rights reserved.
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An experiential exercise in learning

• Form groups of 3.
• If one of you had or has known someone who is
  schizophrenic, depressed or unwell, I want you to
  act the part including emotional, verbal and as
  much as possible behavioral
• The second person will interview the first to try
  to understand and to offer help in some form
• The third person will be the observer who will
  record his observation as to the interaction,
  comments, lessons for takeaways. He/she will be
  the recorder of significant moments of the
  interaction as well as the lessons learnt from
  observing and hearing the conversation