Common Psychiatric

Problems In PHC
Done by;
ZAID ALMUBARAK
YAZEED ALSUBAIE

The prevalence of anxiety, depression and somatization

in Saudi Arabia

The etiology of anxiety, depression and somatization

Clinical features and management in family medicine

setting

Use of Tricyclic antidepressants (TCA) and Selective

serotonin reuptake inhibitors (SSRIs)

Counseling and psychotherapy

Referral

MCQs
1- A 41-year-old man presented with a 3-week-history of
lack of motivation, fatigue, excessive self blame, poor
appetite, social isolation, and delaying his tasks. He has
no previous history of psychiatric or medical disorders.
What is the most likely diagnosis?
a)

Major Depressive Disorder, recurrent type.

b)

Dysthymic disorder.

c)

Major depressive Disorder, single episode.

d)

Depression due to underlying medical problem.

MCQs
2- A depressed patient should be referred to
psychiatric clinics when the patient displays:
a)

Loss of appetite

b)

Fatigue

c)

Diminished pleasure

d)

Suicidal thoughts

MCQs
3- In order to diagnose General Anxiety Disorder
(GAD), the symptoms of anxiety and excessive
worrying must be present of at least:
a)

Month

b)

3 Months

c)

6 Months

d)

1 Year

MCQs
4- According to DSM V criteria for diagnosing mental
disorders a patient showing 3 to 4 depressive
symptoms over a period of more than two years is
diagnosed with:
a)

Minor depression

b)

Major depression

c)

Dysthymia

d)

Bipolar depression

MCQs
5-

Somatization usually occurs with:

a)

Medical diseases/Physical diseases

b)

Anxiety disorders or/and depression

c)

Neurodevelopmental disorders

Depression

Case Scenario

Ms. Amal is a 27-year-old single woman works as a

teacher. She has a five-week history of low mood,
chest tightness, poor appetite, disturbed sleep,
excessive guilt feelings, and loss of interest in her
social activities. Her father has a history of mood
disorder.

Definition

Depressive disorders are characterized by

persistent low mood, loss of interest and
enjoyment, neurovegetative disturbance, and
reduced energy, causing varying levels of
social and occupational dysfunction.

prevalence of depression

According to the World Health Organization (WHO), depression is

a common mental health disorder, affecting more than 350
million people of all ages worldwide. In 2001, the WHO
identified depression as the fourth leading cause of disability
and premature death in the world. It is projected to become the
leading cause of burden of disease by 2030.

World Health Organization notes more than 75% of people with

depression in developing countries are inadequately treated.

A new study found that the Middle East, including Saudi Arabia
has a very high rate of major depression compared with the rest
of the world - almost 7%.

Etiology of Depression
The causative are multifactorial
GENETIC
FACTORS

BIOLOGICAL
Reduced level of
.NE,5HT, &DA

As supported by family
and twin studies

PSYCHOLOGICAL
Stressful events.
Premorbid personality
factors.
Cognitive distortions

Classifications of
Depression
According to the DSM Classification :
o

Major Depressive Disorder.

Dysthymic Disorder (Chronic Depression).

Postpartum Depressive Disorder.

Seasonal Depressive Disorder (Usually in Winter)

Unspecified Depressive Disorder

Clinical Features
Mood Changes :

A.
1.

Feeling low.

2.

Lack of enjoyment and inability to experience

pleasures (Anhedonia).

3.

Irritability (Bad Mood).

4.

Frustration (Defeated or Nothing is Right).

5.

Tension (Under Pressure).

Clinical Features Cont.

B.

Appearance & Behavior :

1.

Neglect Look (dress, hair etc.).

2.

Facial Appearance of Sadness:

Tearful eyes.

Reduced rate of blinking.

Head is inclined forwards.

Down cast gaze.

Turning downwards of the corners of the mouth.

3.

Psychomotor Retardation (slow movements &

interactions).

4.

Social Isolation and Delay of Tasks.

Clinical Features Cont.

Biological Features :

C.
1.

Changes in Sleep, Appetite and Weight

(Increase/Decrease).

2.

Low Energy.

3.

Low Libido.

4.

Change in Bowel Habit (Constipation).

5.

Change in Menstrual Cycle (Amenorrhea).

6.

Diurnal Variation of Mood (Worse at Morning).

7.

Several Immunological Abnormalities (Low

Lymphocytes which increase the risk of infection).

Clinical Features Cont.

Cognitive Features (Thinking):

D.
1.

Poor Attention, Concentration and Memory.

2.

Remembering Negative Memories, Feeling Guilty, Not

Seeing a Future and Negative Thinking of the Present.
Psychotic Features :

E.
1.

Delusions (Guilt, poverty or lost functions of body

etc.).

2.

Hallucinations (Hearing sounds or sense death).

Major Depressive Disorder

Criteria for Major Depressive Disorder :
A.Presence of a single or more major
depressive episode.
B.There has never been a manic episode, a
mixed episode, or a hypomanic episode.

Major Depressive Episode (MDE)

Duration

2-weeks

of the following symptoms:

1. Low mood.

2. Loss of interest.

3. Appetite or body weight change (increased or decreased).

4.Insomnia or hypersomnia. 5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy. 7. excessive guilt. 8. Diminished
concentration. 9. Recurrent thoughts of death or suicide.
at

least one of the symptoms is either no.1 or no.2

Significant
Not

impairment in functioning.

due to substance abuse , a medication or a medical condition

(e.g., hypothyroidism).

DYSTHYMIC DISORDER
Diagnostic Criteria:

2 of the mentioned clinical features for at least 2 years.

During the 2 years the has to be no major depressive

episode.

There has never been a manic episode, a mixed episode, or

a hypomanic episode.

The symptoms are not due to the direct physiological effects

of a substance (e.g. a drug of abuse, a medication) or a
general medical condition (e.g., hypothyroidism).

Management plan
1.

Admission or not?

2.

Education and Reassurance.

3.

BioPsychoSocial approach.

Indications for admission

1.

2.

3.

Danger to self
Danger to others
Total inability to function

4.

Drug resistance cases

5.

Observation and

clarify Diagnosis

Full clinical response in 6-8 weeks in major depression disorder.

SSRI
Uses:
Depressive disorders.
Anxiety
phobia
panic disorders.
Obsessive compulsive disorder.
Premature ejaculation.

S/E

Headache

Nausea

Stomach ache

Decrease libido

Wight gain

Sedation

TCA
Uses:
Depressive

disorders.

Anxiety.
Obsessive

compulsive disorder.
Tricyclics are dangerous in overdose and
should be avoided with suicidal patients.

S/E
Headache
Nausea / vomiting
Dry mouth
Constipation
Cardiac problems
Decrease libido
sedation

Prognosis
Depends on:

Dx

Severity

Duration

Support

Compliance

Approximately 20 weeks for recovery.

Relapse in 25% of patients.

Anxiety

Case Scenario
Ali, 45 year old, locksmith. He has longstanding
and persistent worries that he has not done his
job properly. He worries he might have given
customers the wrong change whenever they
have paid him in cash. Ali informs you that he
worries about many things in his life, and his
most common thought is what if?

Case Scenario
He often imagines the worst happening and states
that when he worries, he often feels sick, has
headaches, feels butterflies in his stomach and is
aware of his heart pounding. Ali often gets hot and
sweaty and says his symptoms makes it difficult to
concentrate and do his job. He is very distressed by
his constant worrying and regards it as a sign of
weakness

Definitions

Anxiety: subjective feeling of worry, fear, and

apprehension accompanied by autonomic symptoms,
caused by anticipation of threat/danger.

Anxiety disorders: are a group of abnormal anxiety states

not caused by an organic brain disease, a medical illness
nor a psychiatric disorder.

Generalized anxiety disorder (GAD): is characterized by

excessive and persistent worrying that is hard to control,
causes significant distress or impairment.

Types Of Anxiety Disorders:

Generalized Anxiety Disorder (GAD)

Panic Disorder.

Agoraphobia.

Social Phobia.

Specific Phobia

Prevalence in KSA

A cross-sectional study was conducted to estimate

the prevalence of mental health problems among
Saudi university students in Saudi Arabia. The sample
size was 1696 students of both genders from ten
colleges.

Study result: generalized anxiety disorder was

reported in 14% of the Saudi students.

Etiology
The actual cause of generalized anxiety disorder is unknown,
but many factors can contribute to the development of
generalized anxiety disorder including:

Genetic factors

Environmental factors: such as stress and trauma

Developmental factors: exposure to traumatic experiences in

childhood

Metabolic factors: such as hyperthyroidism

Symptoms & signs

Features of Anxiety:
Psychological

Physical

Excessive worries & fearful

anticipation.

Chest: chest discomfort & difficulty in

inhalation.

Feeling of restlessness/irritability.

Cardiovascular: palpitation &cold

extremities.

Hypervigilance.

Neurological : tremor, headache,

numbness

Difficulty concentrating.

Gastrointestinal: disturbed appetite,

dysphagia, epigastric discomfort &
disturbed bowel habits.

Subjective report of memory

deficit.

Genitourinary: increased urine frequency,

low libido, erectile dysfunction, impotence
& dysmenorrhea.

Sensitivity to noise.

Musculoskeletal: muscle tension, joint

pain, easily fatigued.

Sleep: insomnia / bad dreams.

Skin: sweating, itching, hot & cold skin.

Diagnosis
DSM-IV Diagnostic Criteria for GAD:
A.

At least 6 months of "excessive anxiety and worry" about a

variety of events and situations.

A.

There is significant difficulty in controlling the anxiety and

worry.

B.

functional impairment in social/ occupational/ or other areas

Diagnosis con.
D.

E.

The anxiety and worry are associated with 3of 6

Restlessness
easily fatigued.
Difficulity concentrating.
Irritability
muscle tension
Sleep disturbance.
Not caused by other psychiatric , medical or
substance abuse conditions.

Management

An important part of any intervention with a patient

with an anxiety disorder is education.

Rule out medical causes.

In general, anxiety disorders are treated with

Cognitive-Behavior Therapy (CBT), medication or
both.

Treatment choices depend on the problem and the

persons preference.

Cognitive Behavioral
Therapy;

Cognitive component;

Detection and correction of wrong thoughts & illogical

ways of reasoning .

Behavioral component;

Relaxation training.
Exposure to feared situation.
The patient is trained to overcome avoidance.

Pharmacotherapy
Antidepressants

First-line Medications:
Selective-serotonin Reuptake Inhibitors (SSRIs)
(e.g. paroxetine 20mg)
SNRIs ( e.g. Venlafaxine 150mg).
Second-line Medications:
Tricyclic Antidepressants (TCAs)
Benzodiazepines: Acute Management, for a
limited period (to avoid the risk of dependence),

Somatoform disorder
Somatic Symptom and Related Disorders (DSM -5)

Case scenario
A 25-year-old female college student sought medical attention
for recurrent multiple somatic complaints. Her list of symptoms
included gastrointestinal difficulties, painful menstruation,
nausea, weakness, malaise, fatigue, headaches, back pain, and
disturbed sleep. During the assessment, a complete history was
taken of the current symptomatic complaints, associated
symptoms, and behaviors, Information was also obtained about
her childhood, family, education, and medical, and psychiatric
treatment. The history revealed that she remembers a normal
childhood and that she is close to her mother.

Physical problems, which the client considered minor at that

time, started during her last year of high school and continued
to worsen to the present. Her mother took her to numerous
physicians in an attempt to find solutions to her complaints. As
a result, narcotics were prescribed and the client developed an
addiction. Furthermore, exploratory laparotomies and multiple
diagnostic procedures were performed, yet no organic cause
was found. She expressed frustration that several doctors told
her that she was a chronic complainer who didnt have anything
wrong with her.

What are Somatoform disorders ?

Are a group of disorders in which physical symptoms
are the main complaints and cannot be explained fully
by a medical condition, a direct effect of a substance
or a mental disorder.

Types of somatoform disorders:

Somatization

disorder

Hypochondriasis
Body

dysmorphic disorder.

Conversion
Pain

disorder

disorder.

Somatization disorder

Somatization disorder is a chronic condition in which a person has

physical symptoms that affecting multiple organs system.

Can not be explained adequately based on physical examination and

laboratory investigations.

The symptoms are not intentionally produced.

It is a associated with excessive medical help-seeking behavior.

It can leads to significant distress and functional impairment (social,

occupational...).

Prevalence of Somatization
Disorder in Saudi Arabia

A study was conducted in a primary health care in Saudi

Arabia to assess the prevalence of somatization disorder.

The sample size was 224 including 104 males and 120
females.

The prevalence of somatization was 16%.

Women displayed higher levels of somatization than

men.

Clinical features

Pain symptoms

headache, chest pain, abdominal pain, back pain, joint pain,

painful urination (dysuria), painful sexual intercourse and
painful menstruation (dysmenorrhea).

GI symptoms

nausea, vomiting, difficulty in swallowing and diarrhea

Cardiopulmonary symptoms

shortness of breath (dyspnea), and palpitation.

Other symptoms

dizziness, double or blurred vision

SOMATIZATION DISORDER

Management

A strong doctor-patient relationship is a key to

getting help with somatoform disorders.

Seeing a single health care provider with

experience managing somatoform disorders can
help cut down on unnecessary tests and
treatments.

The focus of treatment is on improving daily

functioning, not on managing symptoms.

Stress reduction is often an important part of

getting better. Counseling for family and friends
may also be useful.

Management
Cognitive

Behavioral Therapy;

helps relieve symptoms associated with somatoform

disorders. The therapy focuses on correcting:

distorted thoughts

unrealistic beliefs

behaviors that prompt health anxiety

Hypochondriasis
People with this type are preoccupied with concern
they have a serious disease. They may believe that
minor complaints are signs of very serious medical
problems.
For example, they may believe that a common
headache is a sign of a brain tumor.

Body dysmorphic disorder

People

with this disorder are obsessed with a physical

flaw. Patients may also imagine a flaw they don't have.
The worry over this trait or flaw is typically constant. It
may involve any part of the body.

Conversion disorder

Conversion disorder. This condition strikes when

people have neurological symptoms that can't be
traced back to a medical cause. For example,
patients may have symptoms such as:

paralysis

blindness

hearing loss

loss of sensation or numbness

Stress usually makes symptoms of conversion

disorder worse.

Pain disorder

People who have pain disorder typically experience

pain that started with a psychological stress or
trauma.

For example, they develop an unexplained, chronic

headache after a stressful life event.

Management of Common
Psychiatric Problems:
Counseling
Consoling

helps people to solve

stressful problems by decision
making.

The

counselors role: helping the

patient to choose decision among
alternative courses of actions

Management of Common Psychiatric

Problems: Psychotherapy
Psychotherapy: is a therapy used to treat people with a mental
disorder by teaching them strategies and giving them tools to
deal with stress and unhealthy thoughts and behaviors.
Cognitive Behavioral Therapy (CBT): is one of psychotherapy types and
it aims to change a person's thinking to be more adaptive and healthy.
Behavioral therapy focuses on a person's actions and aims to change
unhealthy behavior patterns.
Cognitive behavioral therapy can be applied to treat many mental
disorders such as:

Depression.

Anxiety disorder.

Somatiforme disorder.

When to refer a patient to a

psychiatrist?
Suicidal

patients

Psychotic

symptoms

Substance

abuse/addiction

Sleep

problems

Desire

to treat the patient with

psychotherapy or electroconvulsive
therapy

MCQs
1- A 41-year-old man presented with a 3-week-history of
lack of motivation, fatigue, excessive self blame, poor
appetite, social isolation, and delaying his tasks. He has
no previous history of psychiatric or medical disorders.
What is the most likely diagnosis?
a)

Major Depressive Disorder, recurrent type.

b)

Dysthymic disorder.

c)

Major depressive Disorder, single episode.

d)

Depression due to underlying medical problem.

MCQs
2- A depressed patient should be referred to
psychiatric clinics when the patient displays:
a)

Loss of appetite

b)

Fatigue

c)

Diminished pleasure

d)

Suicidal thoughts

MCQs
3- In order to diagnose General Anxiety Disorder
(GAD), the symptoms of anxiety and excessive
worrying must be present of at least:
a)

Month

b)

3 Months

c)

6 Months

d)

1 Year

MCQs
4- According to DSM V criteria for diagnosing mental
disorders a patient showing 3 to 4 depressive
symptoms over a period of more than two years is
diagnosed with:
a)

Minor depression

b)

Major depression

c)

Dysthymia

d)

Bipolar depression

MCQs
5-

Somatization usually occurs with:

a)

Medical diseases/Physical diseases

b)

Anxiety disorders or/and depression

c)

Neurodevelopmental disorders

References

M. A. Al-Sughayir - Manual of Basic Psychiatry

Sartorius N, Ustun B, Silva J, Goldberg D, Lecrubier Y, Ormel J et al. An International Study of Psychological
Problems in Primary Care: Preliminary Report From the WHO Collaborative Project on Psychological Problems in
General Health Care. Arch Gen Psychiatry 1993; 50: 819-

Prevalence of mental illness among Saudi adult primary-care patients in Central Saudi Arabia Abdallah D. AlKhathami, MBBS, ABFM, Danny O. Ogbeide, FWACP, FRCGPSaudi Med J 2002; Vol. 23 (6) www.smj.org.sa

Oxford Handbook Of Psychiatry 2nd Edition

American Academy of Family Physicians www.aafp.org/afp/2009/0501/p785

National Institute For Health And Clinical Excellence www.nice.org.uk/nicemedia/live/13476/59320/59320.pdf

Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, World Health Organization
(http://www.who.int/mental_health/evidence/atlas/profiles/sau_mh_profile.pdf?ua=1 )

Rates of Depression in The Middle East Alarming (http://www.saudihealthexhibition.com/en/Industry-News/Rates-ofDepression-in-The-Middle-East-Alarming-/ )

Mental Health Atlas 2011 - Department of Mental Health and Substance Abuse, World Health Organization
(http://www.who.int/mental_health/evidence/atlas/profiles/sau_mh_profile.pdf?ua=1 )

Rates of Depression in The Middle East Alarming (http://www.saudihealthexhibition.com/en/Industry-News/Rates-ofDepression-in-The-Middle-East-Alarming-/ )