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Today's presentation is limited to ADULTS. Short forms will be used .... Epilepsy. West Africa. Anx 66. Dep 84. [6] ... based study. Large (largely seizure-free or.
Anxiety associated with medical conditions A/Prof C. B. Khare Senior Consultant Dept of Psychological Medicine

Research Clinical Care Education

1 | 1.1 Topic goes here | Project number | 14.12.08

Copyright © 2008 National University Health System

Agenda - Dr Khare - Introduction - Impact of Comorbidity

- Dr Rathi Mahedran - Diagnostic issues

- Dr Terence Leong - Therapeutic issues

- Discussion

Notice Today’s presentation is limited to ADULTS

Short forms will be used • OCD = Obsessive compulsive disorders • PTSD = Post traumatic stress disorder • GAD = Generalized anxiety disorder

Extent of the problem

Anxiety disorder is a common comorbidity that is easily recognizable and treatable in primary care

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Copyright © 2008 National University Health System

Medical causes of anxiety

Few medical conditions associated with Anxiety Delirium Diabetes IBS Asthma Epilepsy Parkinson’s disease SLE COPD Eating disorders

Head injury Tourette Syndrome Stiff-person syndrome Joint hypermobility Takotsubo Cardiomyopathy

Fahr's Disease Pregnancy Chronic renal failure Pheochromocytoma Stroke Hypertension Myocardial Infarction Hyperthyroidism Hypothyroidism

How significant is the problem? Ref

Setting

Sample

Preval %

Gen Pop

Gen Pop (Adult)

24.9 *

Anxiety disorder

[4]

Gen Hosp.

Outpatients

10-20

Had significant anxiety

[2]

Gen Pop

Chronic med conditions (n=2554)

11

attributable to a medical cause in 10-40% cases

[3]

Gen Hosp. ICU

ICU ref to psych (n=309)

12.94

Anxiety was 3rd most common cause of psych referral.

[1]

Primary care

DM,HPT,IHD (n=2,494)

14-66

Had 1 or more anxiety disorder

[5]

Life Time prevalence (*) All others, point prevalence

Delirium

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Delirium •

Delirium is a common hospitalized patients o At admission 14-24% [1] o Occurs during hospitalization 6- 56% [2]



High risk: elderly, surgical and ICU



Consequences o It is associated with prolonged LOS [3]



A review of 8 studies [4] o (n=1,343) prevalence of • Anxiety disorder 10%[5] • PTSD 18%[5] ,14% at 6 months[6], 10% at 2 yrs[7]

Delirium in ICU •

Risk factors found to be associated with PTSD • • • •

Acute respiratory distress syndrome (ARDS) Agitated delirium [3] Lorazepam use was independent factor [1] Midazolam use [2]

Dexmedetomidine (Precedex) An α2-adrenergic agonist • Used in ICU as Adjunct for sedation and GA • Provides o Sedation without respiratory depression. o Less PTSD incidence than with benzo o Less delirium, tachycardia and hypotension but more bradycardia[1]

Diabetes

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Diabetes: association with anxiety disorders Population

Sample

Prevalence %

Implication

Ref

DM

N= 140 pancreas transplantation

GAD 28 MDD 19.3

On transplant outcome: None detected

[1]

DM type 1 and type 2

Patients

Any Anx 44.4 Phobia 26.5 GAD of 41

Treat-related? vs

[2]

Any Anx 37.5

Genetic association? vs

[2]

Disease related?

[2]

GAD 31.7

Genetic association?

[4]

1st degree relatives

GAD 9.5

Similar increase in MDD

[4]

in an out-patients (n=634)

Anxiety 49.2 Dep 41.3

Higher than other med pts

[5]

Explained by complications

[5]

1st degree relatives

Poorer control Higher the (higher the HbA1C) prevalence DM Type 1 DM

With Complications Risk variation vs without 5-7 to 82-92 DM Type

Typ 1 (n=37) Typ2 (n=46)

Anx 5 Dep 37.8 Anx 4 Dep 15.2

(phobia 6-7 x Gen pop risk)

(possible – Inj,compliance)

Cognitive function in [6] both groups was normal.

Diabetes •

A study [1] of 58 patients with poor glycemic control • 27.6% had symptoms of GAD • Randomized double blind, placebo controlled 8-week • Alprazolam up to 2 mg a day vs placebo • Significant reduction in glycosylated hemoglobin level in the alprazolam group (P=0.04)



Conclusions: • Was not a function of compliance behavior • Probably not directly related to changes in anxiety



Does alprazolam improve glucose regulation through independent mechanisms?[1]

Diabetes • A study [1] of effects of reducing stress on 20 DM II patients • Treated with an anxiolytic (flu-diazepam) for 12 weeks. • Glycosylated hemoglobin levels were monitored • Improvement in the trait anxiety scores was correlated with decreases in glycosylated hemoglobin levels. P50

[2]

Secondary care

Dep 20-55

[3]

Secondary care

Anx >50

[4]

Epilepsy

West Africa

Anx 66 Dep 84

[6]

Epilepsy

Togo

Anx 84.1 Dep 85.3

[6]

Anx 22.8* Dep 17.4*

[7]

N= 153

Anx 39.4 Dep 24.4

[8]

n=196,

Anx 38.8

[9]

pop-based Epilepsy Door-to Door survey- Epilepsy

Epilepsy

1 year prevalence(#), Life time prevalence(*), all others are point prevalence

Chronic/Refractory seizures -- Anxiety



The highest rates of psychiatric comorbidity (including anxiety) are reported in patients with chronic refractory seizure disorders [1][2][3][4][5][6] and poor seizure control [9][10][11] (inaddition to next slide)



No relationship found by a few between anxiety and • Seizure frequency [8] or to the • Duration of epilepsy, or the frequency of partial complex seizures [7]

Epilepsy - - Anxiety Population Chronic epilepsy

Sample

Preval %

Implication

Ref

Using HADS, 14.4% had clinical anxiety Risk factors: Female, high frequency of seizure activity

[3]

n=126

Anx 39 Dep 20

Community based study

Large (largely seizure-free or infrequent)

Anx 25

mean of 6.8 on the HAD scale Risk factors: High frequency of seizure activity

[4]

Epilepsy (mean disease duration of 13.9 ± 9.5 yrs)

N=201

Anx Dep

Independent risk factors: females, high seizure frequency, symptomatic Focal epilepsy explain 1214% variance

[1]

Epilepsy >> Focal >>Temporal and Anxiety •

Anxiety is more severe among patients with focal epilepsy [6]



The origin and type of seizures [5]



Temporal lobe epilepsy [3] with amygdala involvement [4] o Complex partial seizures (temporal) is a risk factor for depression and anxiety [1][2][3][4][6][7][8][9] o In community samples of TLE: - Anxiety: 19%, Depressive disorder 11% in TLE [2] o In surgical candidates 24.7% [1] - One study [12] could not confirm a link with the left temporal lobe



Frontal lobe epilepsy and primary or generalized seizures [10][11]

Is treatment responsible for anxiety in Epilepsy? •

The use of antiepileptic drugs is related with interictal anxiety o Topiramate [1] o Felbamate. [2] o Primidone [3]

Cause of Epilepsy - and anxiety



In one study [1] (n=196) in which only 23.5% of patients had a good seizure control, anxiety was associated with: o 35.7% of cases of cryptogenic (idiopathic) and o 10.2% that were post-traumatic

o

Compared to the other types, after controlling for other factors

Epilepsy – Anxiety Do psychological factors play a role? •

Anxiety in Epilepsy patients was related to o Psychological factors [1] - Low schooling, a community sample [2] associated with  Anxiety (OR 2.8, 95% CI 1.2 to 6.5)  Depression (OR 3.8, 95% CI 1.6 to 9.0)

o Stigma may mediate between Epilepsy and anxiety or poor QOL

Phases of epilepsy and anxiety • Preictal anxiety o Precedes the onset of seizures by hours or days [2] • Ictal anxiety nervousness, fear, anger and irritability occur o As a partial seizure or o an “aura” of a complex partial seizure [3]; esp in TLE (10%–15% lat foci and 15%–20% medial foci) [4][5]

o Ictal foci in other locations are related to ictal fear [6]

• Postictal fear may last up to 7 days after the seizure • Interictal anxiety (Anxiety without temporal relationship with seizures [6]) o Manifests as panic disorder, GAD, or OCD [7]

Epilepsy - Age of onset and anxiety

Association of anxiety with: •Early age of onset of epilepsy [3] - But not found in another study [2]

•Late life onset of epilspesy [1] - But not found in another study [2]

Epilepsy – and type of anxiety Panic attacks/disorder •

Prevalence of panic disorder in Epilepsy patients: o Up to 6 times more (point-)prevalent (15–30%) [1][2][3][4] compared to 3.5% in the gen. pop.

o 5–21% prevalence [3][5]



D/D Panic attacks and seizures: - Of all the types of anxiety disorder, panic is most likely to be generated by a seizure into ‘‘ictal fear’’

Epilepsy - phobia • Common phobias in epilepsy are o Fear of seizures or [1] o Fear accidents  (may lead to agoraphobia) [1]

o Fear of social embarrassment  (may lead to Social phobia) [1]

Epilepsy impact (1) • Anxiety and depression is associated with increased healthcare costs of epilepsy[1] • Effects of social isolation, social phobia, agoraphobia • Other effects - Memory problems - Scholastic backwardness

Epilepsy – Types of anxiety OCD •

Prevalence of clinically significant obsessional symptoms in 22% of TLE patients compared to 2.5% of healthy controls [3].



Case reports of epilepsy and comorbid OCD [4][5][6][7]



Obsessive thoughts May occur as a part of an epileptic aura in TLE in the form of ‘‘forced thinking’’ [1][2]

Epilepsy with anxiety - QOL •

Associated with poor quality of life,[4][5][6] •



In one study depression (12%) and anxiety (27%) explained more variance in HRQOL than did any other seizure-related (e.g. 3% for seizure frequency) or demographic variable [5]

QOL Poor in temporal lobe epilepsy [4].

Epilepsy

[1]

[1]

[1]

Thank you for your attention

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Copyright © 2008 National University Health System