Somatic phenomenology in depression

1. Dr. Ahmed Albehairy, M.D
Psychiatry Consultant

2. Depression :
- Major depressive disorder: 5-25 %
LT prevalence.
- Recurrent MDD: 3% LT prevalence.
- Dysthymia : 6 %LT prevalence.

4. Definition of somatic sx in depression:
 Various bodily sensations that a depressed individual
perceives as unpleasant or worrisome.

5. Psychopathology of somatic sx
 Vital feelings.
 Coenstopathic state.
 Vital disturbances vs. vegetative sx.
 Painful vs. non painful sx.

6. Diagnosis :
 ICD- 10
F32 - DEPRESSIVE EPISODE
Without somatic syndrome
With somatic syndrome
 DSM IV and 5 …..no somatic specifier.

7. Somatic sx. In depression and rates of
diagnostic recognition within primary care
 The typical form of presentation of depression is via
somatization.
 So , that affects the treated depressive disorders in only
60% of affected patients .
 At least 20 – 30 % of patients with chronic medical
conditions suffer from a coexisting depression.
 About 50% of the depressed patients report somatic sx
exclusively ,
 Somatic sx in depression have overlapped impression with
unexplained medical sx, hypochondriasis, functional
somatic syndrome, and somatoform disorders.

8. Physicians Diagnose Depression
In Response to Psychosocial Presentation
The relationship of presenting physical complaints to depressive symptoms in primary care patients.Gerber PD,
Barrett JE, Barrett JA, Oxman TE, Manheimer E, Smith R, Whiting RD , J Gen Intern Med. 1992 Mar-Apr; 7(2):170-
3.
77
23
0
10
20
30
40
50
60
70
80
rate of
physician
recognition
& diagnosis
psychosocil c/o
somatic c/o

9. Physical Symptoms as Predictors
of Depression
The relationship of presenting physical complaints to depressive symptoms in primary care patients.Gerber PD,
Barrett JE, Barrett JA, Oxman TE, Manheimer E, Smith R, Whiting RD , J Gen Intern Med. 1992 Mar-Apr; 7(2):170-3.
+ve predictive value
sleep
disturbance
fatigue
3co
msk
backache
shortnessof
breath
vagueco
61 60 56
43 39 39 37
0
10
20
30
40
50
60
70

10. Somatic symptoms and depression are
interviewed
What you see may be what you
are looking for.

11. Somatic Symptoms In Depression
-fatigue
-headache
-disturbed sleep
-dizziness
- chest pain
- vague joint / limb pain
- GIT complaints ( nausea, vomiting,diarrhea)
- sexual dysfunction / apathy
- menstrual problems

12. Aspects facilitating somatic sx in
depression
 Female .
 Younger.
 Stress and trauma.
 Anxiety sx.
 Less satisfaction from care.
 Culture and society.
 Dr.- pt relation ship
 Mode of presentation, ages, medical conditions, lower
income, imprisonment.

13. -Unrecognized depression has higher morbidity and
mortality rates in medically ill patients, though they are not
more severely medically ill.
Simon GE et al. N Engl J med. 1999; 341:1329-1335
Silverstone PH,et al, Cand J Psychiatry, 1996;67-74
Frauseure-Smith N, et al. Circulation, 1995; 91:999-1006

14. Burden of somatic sx in depression
 Fail to reach full remission.
 Still suffering from residual sx.
 Significant relation between depression and painful
physical conditions.
 Depressed pts with chronic pain sx reported longer
duration of depressive mood.
 Higher risk of suicide.
 Higher risk of relapse.
 Worse out come.

15. Kaplan-Meier survival
estimate
0.8
1.0
0.9
0 24 48 72 96 120 144
Kaplan-Meierestimate
Survival time (weeks)
Non-depressed
patients
Depressed
patients
Katon et al. Diabetes Care 2005; 28 (11): 2668–2672
Depression increases mortality rate in
diabetes by two-fold

16. Depression is a risk factor for Stroke
and Coronary Artery Disease
Independent of age, gender, lifestyle.
Increased Platelet Activation, reversed
by SSRI’s.
Likelihood of developing myocardial
infarction 4X
Likelihood of stroke 2.6 X general
population
son et al, Stroke. 2001;32:1979; Yamanaka et a l, Biomed Pharmacother. 2005 Oct; 59
Suppl 1:S31; Marzari et al, J Gerontol A Biol Sci Med Sci. 2005;60(1):85-92

17. Depression after Coronary Artery Disease is
associated with Heart Failure ( survival rate)
May et al. J Am Coll Cardiol
2009; 53 (16): 1440–1447
Days to heart failure admission
0.5
1.0
0.7
0 1,000 2,00
0
3,00
0
4,000 5,00
0
Event-freesurvival
0.6
0.9
0.8
No depression diagnosis
Depression
diagnosis

18. Central effect : mental tiredness
5HT, NE, Dopamine , cholinergic,. Glutamate, &
Histamine
Peripheral effect :
-5HT, NE, Dopamine, glutamate , substace P.

19. Pathogenesis of Somatic Symptoms in
Depression
 Desynchronization of the sleep-wake cycle .
 Reduced concentrations of brain-derived neurotropic
factor (BDNF) causing Impaired neuroplastlcity, cell
resistance, and neurogenesis.

20. ABC of psychological medicine Abdominal pain and functional gastrointestinal disorders, By Sue
Davis,2014-10-13 23:22

21. Superficial NK1-expressing neurons control spinal excitability through activation of descending pathways.
Nature Neuroscience 5, 1319 - 1326 (2002)

22. Pathogenesis of Somatic Symptoms
in Depression
( Chronic pain conditions and depressive mood )
Hypothalamic – Pituitary – Adrenal Axis.
Disordered feed back mechanism of CRF ,ACTHA &
Cortisol stress response ------- Dec hypocretin----
Desynchronization of the sleep-wake cycle ----inc
production of proinflamatory cytokines -----depletion
of serotonin system --- Reduced concentrations of
brain-derived neurotropic factor (BDNF) causing
Impaired neuroplastlcity, cell resistance, and
neurogenesis.

23. Treatment of somatic sx
 The goal is to achieve a state of symptomatic treatment
in depression.
 Targeting both serotonin and norepinephrine
neuronal circuits , e.g SNRI .TCA , DRI, Atypical DRI
and NaSSA.
 Targeting dopaminergic pathways.
 THC , ??? Sleep pattern and pain relief.
 Antiglutamate??
 Lithium and tri-iodothyrodine.
 OMEGA 3 , Exercise , Relaxation , and CBT.