인제대학교 서울백병원 김원 - anxiety · 2011-06-09 · change on somatic symptoms...
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* low energy
* psychomotor retardation
* poor concentraion
* psychomotor agitaion
* decreased sleep
* decreased appetite
controls past MDD current MDD
* < 0.05
Psychiatry Res, 2002
Painless somatic symptoms in depression ◦
vague and exaggerated multiple somatic complaints (usually ≥ 3)
fatigue, weakness, non-specific and painless musculoskeletal problems, sensations of heaviness or lightness in at least one part of the body, gastrointestinal dysfunction, shortness of breath, palpitations, dizziness, double vision, changes in sleep patterns and appetite, and polyuria
Painful somatic symptoms ◦
joint pains, lumbar pain and headache
Age, female gender, and unemployment◦
associated with the presence of somatic symptoms.
The severity of the depression is greater in patients with moderate to severe discomfort due to somatic symptoms.
emphasize psychological sx. as key fx. of MDD◦
underestimate somatic depression
Masked depression in primary care◦
1st stage, 442 patients, 1.8% prevalent.◦
2nd stage, 62 patients with high somatization score, 39 (63%) prevalent.◦
Most were diagnosed with Musculoskeletal disease◦
Underestimation is crucial in minority population.
Posse and Hallstrom, 1998
Nakao and Yano (2006)◦
1066 Japanese workers (mean age 35 years), ◦
annual health examinations, in 2 successive years, ◦
Prediction of depression in the following year◦
3.4~3.7% MDD seen among the Japanese workers◦
WHO reported that 77% of Japanese depressive subjects complained of somatic symptoms. ◦
Fatigue was the most common and powerful predictor of core depressive symptoms
Insomnia was closely related to depressive mood and diminished interest or pleasure. Headache was the second most common symptom, less predictive than fatigue and insomnia.
Depressed moodMontgomery–Asberg Depression Rating Scale (MADRS)Only 3 items : physical symptomsHamilton depression rating scale (HAM-D)8 items : physical symptoms18/56 point (32%)PHQ-9
Somatic symptoms Patient Health Questionnaire-15 (PHQ-15)Somatic Symptom Inventory (SSI) Visual Analog Scale (VAS) for pain (DeLoach et al., 1998)≥ 20 (on a scale of 0–100)Symptom questionnaire
Patient Health Questionnaire-15 (PHQ-15)◦
self-report, somatic symptom type and severity over, the prior 4 weeks
Somatic Symptom Inventory (SSI) ◦
26-item questionnaire, painless and painful ◦
patients' degree of discomfort for each symptom is rated from 1 to 5 (1 = absent; 3 = moderate; 5 = a great deal)
MADRS relies less than HAM-D does on somatic symptoms.
157 MDD patients
HAMD-17 HAMD-S MADRS MADRS-S
0wk 8wk Change on somatic symptoms correlated with global improvement in MDD.
Improvement in somatic symptoms is highly correlated with a favorable outcome in depression.
Nonremitting responders had a significant smaller baseline-to-end point decrease in somatic symptoms.
Nonremitter vs Remitter based on MADRS
nonremitting responder remitter
J Psychosom Res. 2006
Adapted from: Greco T, et al. J Gen Intern Med. 2004;19(8):813-818.
Nonsomatic depressive symptoms
Nonpain somatic symptoms
Pain somatic symptoms
A Randomized Trial Investigating SSRI Treatment
Baseline 1 Month 3 Months 6 Months 9 Months
Gender differences in prevalence of MDD◦
may be due to the high prevalence of anxious depression, atypical depression and somatic depression in women.
These three subtypes of depression ◦
are also very prevalent during pregnancy, the post partum period, perimenstrually and during the menopause transition (perimenopause) period◦
vulnerability and hormone instability in their pathobiology.
Sensitivity to interpersonal rejection1
Intensified mood reactivity2
Anxious depression phenotype3
Depersonalization or derealization
Lack of energy▪
Subjectively experienced anger
Nonreactivity of mood to changes in circumstances
1 APA, 1994. 2.West and Dally, 1959. 3 Clayton PJ et al, 1991. 4
Silverstein, 1999, 2002.
Diversified pain and aches
Lifetime prevalence of somatic depression◦
(F: 15.2%, M: 7.5%)
but a prevalence of pure depression ◦
(F: 6.9% , M: 6%)
Somatic depression have a tendency with coexisting anxiety disorder
Serotonin (5-HT) and norepinephrine (NE) pathways mediate various functions in the brain1-3
Descending spinal projections modulate nociception2,3
Disturbance in these pathways are thought to be associated with the emotional and physical symptoms of depression3
Dorsal raphe nuclei
Lateral tegmental NA cell system
Changes in appetite/Lack of pleasure
Vague pain in joints, limbs, back,
Modulatory effects on nociception
–Adapted from: 1Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Lippincott Williams & Wilkins; 1998:114-115.
2Fields HL, et al. Annu Rev Neurosci. 1991;14:219-245.3Stahl SM. J Clin Psychiatry. 2002;63:382-383.
Atypical depression ◦
MAOI > TCA , still in debate ◦
SSRI + benzodiazepine
Very few studies◦
TCA = SNRI ? > SSRI◦
TCA + anticonvulsant => gabapentin ?
Antonijevic, 2006; Matza et al., 2003
Venlafaxine, Milnacipran, Duloxetine◦
Analgesic effect via descending pain pathway
0 1 2 3 4 5 6 7 8Week
s*Venlafaxine XR (N=1136)Placebo (N=691)
Venlafaxine XR in the Reduction of Anxiety- Somatization Symptoms Associated with MDD*
In Depressed PatientsEffective in reducing pain associated with depression1
1 Detke et al, 2003
Overall Head Back Shoulder
Effectiveness of mirtazapine in the treatment of depression with associatedsomatic symptoms.
García Campayo. Actas Esp Psiquiatr. 2008 Jan-Feb;36(1):25-32.
Somatic section on HAM-D, SPPI
Antipsychotics for anxious depression ?◦
Omega-3 fatty acid (DHA & EPA)◦
The deficit of omega-3 PUFAs is associated with depression. ◦
Societies that consume a small amount of omega-3 PUFAs appear to have a higher prevalence of MDD. ◦
depressive pt. showed a lower level of omega-3 PUFAs◦
the antidepressant effect of PUFAs had been reported in a number of clinical trials.◦
EPA and DHA are not synthesized in human body and can only be obtained directly from fish.
the role of n-3 fatty acids in psychoneuroimmunology,somatic presentation, and medical illness comorbidity of depression. Su KP, Asia Pac J Clin Nutr.2008
Biofeedback, relaxationExerciseMeditation, Yoga
New dimension of diagnosis
Detailed and precise measurement of somatic symptoms
New pharmacotherapy tailored to…
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