1. Anxiety, Depression, somatization DR.YOUSEF ABDULLAH AL TURKI MBBS,DPHC,ABFM Consultant Family Medicine Associate professor King Khalid University Hospital College of Medicine King Saud University

2. Scenario Ibrahim 40 years old nurse presented to primary care clinic complaining of depressed mood most of the day, loss of interest, insomnia, decreased appetite, hopelessness, and pessimistic and quilty thought. Ibrahim 40 years old nurse presented to primary care clinic complaining of depressed mood most of the day, loss of interest, insomnia, decreased appetite, hopelessness, and pessimistic and quilty thought. HOW YOU WILL PROCEED DURING THIS CONSULTATION? HOW YOU WILL PROCEED DURING THIS CONSULTATION?

3. Epidemiology of Depression Saudi Arabia Saudi Arabia Sex Sex Age Age Marital status Marital status

4. Etiology of Depression Psych social stress commonest Psych social stress commonest - stress at home - stress at home - stress at school - stress at school - stress at work - stress at work - marital problem - marital problem - financial problem - financial problem Biological theory: serotonin, norepinephrin, and dopamine Biological theory: serotonin, norepinephrin, and dopamine

5. Continue Genetic theory Genetic theory Drug and alcohol abused Drug and alcohol abused Unknown Unknown

6. Classification of depression Unioplar : only depression Unioplar : only depression Bipolar : depression / mania Bipolar : depression / mania Major/ minor Major/ minor Old: endogenous/ reactive Old: endogenous/ reactive neurotic/ psychotic neurotic/ psychotic

7. Clinical feature Not every sadness mean depression Not every sadness mean depression Criteria for major depressive episode Criteria for major depressive episode One of the following: One of the following: 1- depressed mood :all the days 1- depressed mood :all the days 2 loss of interest or pleasure : all the days 2 loss of interest or pleasure : all the days

8. continue Five( or more) of the following during the same 2 weeks: Five( or more) of the following during the same 2 weeks: 1- depressed mood most of the day 1- depressed mood most of the day 2- Marked diminished interest or pleasure in al most all activities 2- Marked diminished interest or pleasure in al most all activities 3- decrease appetite/ or increased 3- decrease appetite/ or increased

9. continue 4- insomnia or hypersomnia 4- insomnia or hypersomnia 5- psych motor retardation or agitation 5- psych motor retardation or agitation 6- fatique every day 6- fatique every day 7- feeling of worthlessness/ pessimistic 7- feeling of worthlessness/ pessimistic

10. continue 8- recurrent thought of death 8- recurrent thought of death 9- decreased ability to think and concentrate 9- decreased ability to think and concentrate SUICIDE ???? Severe depression SUICIDE ???? Severe depression

11. Differential diagnosis Normal sadness Normal sadness Hypo thyroids Hypo thyroids Anxiety Anxiety drugs side effects drugs side effects

12. continue Dementia Dementia Parkinson's disease Parkinson's disease Adrenal dysfunction Adrenal dysfunction

13. management Psych social approach: support at: home, work, financial, relationship Psych social approach: support at: home, work, financial, relationship Psych therapy: help patient to decrease stress, and cope with stress Psych therapy: help patient to decrease stress, and cope with stress 1- cognitive psychotherapy : +ve thinking 1- cognitive psychotherapy : +ve thinking 2- ventilation psychotherapy 2- ventilation psychotherapy 3- family suport 3- family suport

14. continue Pharmacological therapy: Pharmacological therapy: Tricyclic antidepressant Tricyclic antidepressant SSRI: selective serotonin re-uptake inhibitor SSRI: selective serotonin re-uptake inhibitor

15. continue effect of drug &Duration of treatment effect of drug &Duration of treatment Compliance to medication: S/E Compliance to medication: S/E When to refer to psychiatrist? When to refer to psychiatrist?

16. Prognosis Good if treated early Good if treated early need psych Social support need psych Social support

18. Scenario Nasser 28 years old Chief manger presented to primary care clinic complaining of excessive worry and sense of impending disaster without evidence of appropriate real danger, started 9 month ago. He had history of muscular ache, abdominal discomfort, dry mouth, palpitation, frequent attack of short ness of breath, cold extremities and wet palm during the last 7 month. Nasser 28 years old Chief manger presented to primary care clinic complaining of excessive worry and sense of impending disaster without evidence of appropriate real danger, started 9 month ago. He had history of muscular ache, abdominal discomfort, dry mouth, palpitation, frequent attack of short ness of breath, cold extremities and wet palm during the last 7 month. HOW YOU WILL APPROACH NASSER? HOW YOU WILL APPROACH NASSER?

19. Epidemiology of Anxiety Saudi Arabia Saudi Arabia Age Age Sex Sex Marital status Marital status

20. Etiology Psych social stress Psych social stress Relationship problem Relationship problem Financial problem Financial problem Anxious Personality Anxious Personality Physical illness Physical illness Genetic theory Genetic theory

21. Clinical feature Normal physiological anxiety Normal physiological anxiety Generalized anxiety disorder: Generalized anxiety disorder: Continuous and chronic state of excessive worry or apprehensive for > 6 months Continuous and chronic state of excessive worry or apprehensive for > 6 months

22. continue Psychological: fear or apprehension, restless ness, initial insomnia, poor concentration. Psychological: fear or apprehension, restless ness, initial insomnia, poor concentration. Physical: muscular ache, headache, bone ache, dry mouth, palpitation, sweating, wet palms. Physical: muscular ache, headache, bone ache, dry mouth, palpitation, sweating, wet palms.

23. Differential diagnosis Physiological anxiety: short duration Physiological anxiety: short duration Hyper thyroid Hyper thyroid drug or alcohol withdrawal drug or alcohol withdrawal Phechromocytoma Phechromocytoma Hypoglycemia Hypoglycemia

24. continue Panic attack Panic attack phobia phobia

25. management Relaxation Relaxation Supportive counseling Supportive counseling Psychotherapy Psychotherapy

26. continue Pharmacological: Pharmacological: B-blocker: physical symptom B-blocker: physical symptom Benzodiazepine : for short period less than1- 2 week WHY? Benzodiazepine : for short period less than1- 2 week WHY? Drug dependence Drug dependence Alternative: small dose of tricyclic anti depressant Alternative: small dose of tricyclic anti depressant

27. prognosis Good prognosis Good prognosis If diagnosed and treated early no recurrent in majority If diagnosed and treated early no recurrent in majority

28. scenario Khalid 35 years old present to primary care clinic complaing of dizziness, backache and indigestion. Khalid 35 years old present to primary care clinic complaing of dizziness, backache and indigestion. His file show: for the last 7 month, he presented with the following: abdominal pain, nausea, intolerance to 15 different foods, backache, shortness of breath at rest, chest pain, dizziness, difficulty swallowing, palpitation. His file show: for the last 7 month, he presented with the following: abdominal pain, nausea, intolerance to 15 different foods, backache, shortness of breath at rest, chest pain, dizziness, difficulty swallowing, palpitation. Investigation: Blood test 5 times chest x-ray 3 times, ECG ( 6 times), ultrasound abdomin (2 times), CT scan abdomin( 2 times), upper Gi endoscopy (2 times), colonoscopy once chest x-ray 3 times, ECG ( 6 times), ultrasound abdomin (2 times), CT scan abdomin( 2 times), upper Gi endoscopy (2 times), colonoscopy once ALL investigations were NORMAL HOW YOU WILL MANAGE KHALID?

29. What is somatization? One of the commonest mode of presentation in general practice One of the commonest mode of presentation in general practice Expression of psychological problems in physical complaints Expression of psychological problems in physical complaints Multiple, recurrent, change physical symptoms Multiple, recurrent, change physical symptoms ? hypochondriasis ? hypochondriasis

30. Clinical features Could be presented by any physical complaint Could be presented by any physical complaint Absence of organic pathology Absence of organic pathology Seen by different doctors and hospitals Seen by different doctors and hospitals Depression and anxiety underlying somatization Depression and anxiety underlying somatization

31. mangement Explain to the patient and family relationship between psych and somatic Explain to the patient and family relationship between psych and somatic Empathic attitude Empathic attitude Avoid unnecessary investigation Avoid unnecessary investigation Treat underlying depression and anxiety Treat underlying depression and anxiety

32. prognosis Somatization likely to be chronic and difficult to treat Somatization likely to be chronic and difficult to treat If treat underlying depression and anxiety early, patient will respond If treat underlying depression and anxiety early, patient will respond

33. conclusion Anxiety, depression, and somatization are common psychiatric illness at primary care level Anxiety, depression, and somatization are common psychiatric illness at primary care level Good consultation and communication skills with patients will help family physician to diagnose psychiatric illness early. Good consultation and communication skills with patients will help family physician to diagnose psychiatric illness early.

34. WITH MY BEST REGARDS WITH MY BEST REGARDS