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
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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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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