Anxiety disorders and autonomic dysfunctions in general therapy
Prevalence of mental disorders in the European Union (number of patients, million, 12 months)
It would seem that anxiety and depressive disorders are a purely psychiatric problem, but general practitioners record an increased referral for certain manifestations of anxiety and depression. At the same time, the doctor does not always correctly interpret these symptoms and, accordingly, can not determine the adequate amount of assistance. Obviously, anxiety disorders, psychosomatic conditions and all kinds of autonomic dysfunctions require an in-depth multidisciplinary approach.
It was on this principle that a series of scientific and practical conferences “Optimization of care for patients with anxiety disorders and autonomic dysfunctions in neurological and general therapeutic practice” were organized , which took place in Kiev, Dnipro, Kharkov, Lvov, Odessa.
The events were attended by therapists, family doctors, cardiologists, neurologists, psychiatrists. It should be noted that all the performances Ob – unifying a comprehensive approach to the problem under discussion, which enabled doctors to get to know the point of view of related specialists to share their opinions, get answers to your questions from leading clinicians country. The scientific part was opened by the chief researcher of the department of psychosomatic medicine and psychotherapy of the Ukrainian Research Institute of Social and Forensic Psychiatry and Narcology of the Ministry of Health of Ukraine (Kiev), Doctor of Medical Sciences, Professor Oleg Sozontovich Chaban , who noted that the prevalence of anxiety-depressive spectrum disorders causes today is a serious concern. So, in the male population, the prevalence of cases of anxiety-depressive states is 8-20%, in the female population it reaches 20-26%. It is noteworthy that among single people this figure is about 2-4 times higher. If before 1950 the average age of patients with such disorders was 40-50 years old, today it is significantly lower – 20-30 years. This worries the medical community (regardless of the specialty of the doctor). The spectrum of anxiety-depressive disorders is dominated by such conditions as anxiety, insomnia, unipolar depression, dementia, alcohol dependence , etc. Oleg Sozontovich emphasized that it is the general practitioners who most often have to deal with the first manifestations of anxiety disorders. At the same complaints, which should alert the dock – the torus are:
• increased irritability, constant feeling of anxiety, concern about the inability to meet the expectations of other people;
• obsessive thoughts about an unsatisfactory financial situation, the inability to focus on other matters because of this , the inability to achieve a state of inner peace; • insomnia and depressing night thoughts, increased fatigue, daytime sleepiness; • pain in the back and stomach area, a frequent feeling of ill health without the presence of somatic reasons.
Most of the manifestations of generalized anxiety disorder (GAD) are somatic character, including: palpitations, fluctuations in blood pressure, shortness of breath, sweating, chills, bowel disorders, chest and abdominal pain, frequent urination, pain with nonspecific manifestations. However, only 13.3% of patients with GAD complain of anxiety.
The relationship between somatic pathology and anxiety disorders is a complex and multifaceted problem. Thus, more than 60% of patients with diseases of the gastrointestinal tract (GIT) have some form of anxiety syndrome. The prevalence of GAD syndrome is with: • allergies – about 50%; • diseases of the spine – 48%; • migraines – 22%; • metabolic disorders – up to 25%.
More than half of patients with neurocirculatory dystonia, ischemic heart disease (IHD), arterial hypertension (AH) also have some form of GAD. The variety of GAD complaints is shown in Figure 2.
Rice. 2. Polysystemic somatic manifestations of anxiety
Why is early diagnosis of anxiety disorders necessary? Professor OS Chaban named the following reasons:
• uncontrolled anxiety is quickly objectified, and internist doctors are directly involved in the consequences of this objectification (psychosomatic manifestations); • against a negative psychoemotional background, the underlying disease becomes chronic, while the quality of life is rapidly declining; • other pathological emotions (most often depression, phobias, hypochondria, importunity) are added to an unrecognized anxiety in dynamics over time.
Oleg Sozontovich noted the high probability of meeting a general practitioner – family medicine with a patient suffering from GAD. According to statistics, during a routine medical reception signs of anxiety observed in the average, 35% of patients with depression – at 40%, phobia and alcohol dependence – at 25%, nar – dependence services – at 16%.
It is important for the internist to be aware of the impact of GAD and / or panic disorder on the somatic health of patients. So, in the presence of these disorders, the likelihood of: • heart disease, including coronary heart disease, increases – 5.9 times; • violations from the gastrointestinal tract – 3.1 times; • pathology of the respiratory tract and migraines – 2.1 times; • AH, infections and dermatological problems – 1.7 times; • joint diseases – 1.6 times; • kidney disease – 1.5 times; • metabolic disorders – by 1.25 times; • allergic pathology – 1.2 times.
Professor O.S. Chaban summarized that chronic anxiety is an ideal background for the development of comorbidities. That is why a timely recognized anxiety-depressive disorder will not only help to fight the existing somatic pathology more effectively , but will also become the most important method for preventing the development of new nosologies.
When prescribing therapy for anxiety disorder, it is important to remember the risk of drug interactions, since it develops against the background of an already existing somatic pathology. In addition, for most drugs, an imbalance in such important parameters as efficacy and safety is typical . So, synthetic psychotropic drugs (benzodiazepines: lorazepam, diazepam, alprazolam, etc.; blockers of histamine receptors: hydroxyzine; selective serotonin reuptake inhibitors: paroxetine, sertraline, escitalopram, etc.; buspirone, etc.) have proven high efficacy due to the implementation of sedative , anxiolytic, antidepressant effects. However, as you know, these drugs are potentially unsafe: they cannot be used for a long time due to their potential to cause addiction and withdrawal symptoms. Taking the above drugs can be accompanied by a number of adverse reactions (drowsiness, excessive sedation, weight gain, headache, nausea, vomiting, sexual dysfunction, sleep disturbances, gastrointestinal disorders , etc.). In this regard, in modern medicine, preparations based on plant extracts (passionflower, hops, valerian, lemon balm, St. John’s wort) are widely used , which have a favorable safety profile. K Unfortunately, the effectiveness of these means is very limited; as a rule, they are not shown when alarming disorders, do not have a pronounced anxiolytic effect. The recently widely advertised drugs last generation means (mebicar, fabomotizole), causing a number of issues in terms of their effectiveness and safety. So, until now, in fact, no placebo-controlled studies have been conducted to study the therapeutic efficacy of such drugs. The safety profile is also poorly understood, with little information on possible drug interactions. The question arises: is there a tool that is both effective and safe?
Oleg Sozontovich noted that a lot of interest in this regard is the preparation Laze (Dr. Willmar Schwabe Pharmaceuticals, Germany), which is a unique active ingredient is sileksan (Silexan ® ) – an extract produced from the flowering tops of Lavandula angustifolia. High-tech processes for the selection of raw materials and production ensure the uniformity of the content and quality of the active ingredients in each batch of the product; it meets the requirements of the monograph Lavender oil of the European Pharmacopoeia (Kasper S. et al., 2010). Lazei mechanism of action is as follows: anxiolytic, antidepressant effect, improving sleep and reduced severity of depletion due to the action potential – operated calcium channels P- and Q-type and modulation of GABA receptors.
The clinical efficacy of the drug Lazeya in the treatment of mild and moderate forms of anxiety disorders has been proven in 16 clinical studies, including placebo-controlled and comparative ones, involving 2200 patients (Table 1).
Looking at the problem from the perspective of a psychiatrist provoked a lively reaction from internist doctors. Further, the multidisciplinary relay race was continued with a report, the topic of which was anxiety disorders in cardiological practice. Scientific curator of the cardiology department of the State Institution “Institute of Gerontology named after D. F. Chebotarev of the National Academy of Medical Sciences of Ukraine “(Kiev), Doctor of Medical Sciences, Professor Viktoria Yurievna Zharinova focused the attention of internists on the frequency of occurrence of anxiety disorders and on providing assistance in general medical practice. As you know, anxiety is an emotional state that occurs in a person in situations undefined hazard. In contrast to fear, which is a response to a specific, very real danger alarm often pointless. Most (up to 80%) patients with anxiety-depressive states (TDS) turn to representatives of primary health care, while internists diagnose no more than 25% of such conditions.
And only 5% of patients with TDS are prescribed adequate therapy. As you can see, the issue of methods for correcting these conditions is extremely relevant in therapeutic practice, primarily in connection with the danger of developing psychosomatic conditions.
Such diseases include hypertension, ischemic heart disease, bronchial asthma, rheumatoid arthritis, gastroesophageal reflux disease, irritable bowel syndrome, neurodermatosis, chronic pain syndrome, alcohol dependence, etc.
The prevalence of psychosomatic disorders in the population averages 45%, reaching 57% in the structure of outpatient admission in the primary network. Today, when the training of family doctors is constantly being improved, the identification of TDS at an outpatient appointment is a fairly common occurrence.
Professor V.Yu. Zharinova emphasized that two main types of complaints prevail in TDS:
• of a mental nature (approximately 25%): anxiety, internal anxiety, feeling of tension, stiffness, inability to relax, increased irritability, memory loss, problems with falling asleep, disturbed night sleep, increased fatigue and phobias; • somatic (approximately 75%): so-called autonomic symptoms, including shortness of breath, increased heart rate, pressure in the chest and / or throat, hot flashes or chills, hyperhidrosis, wet palms, nausea, diarrhea, abdominal pain, dizziness, tremors , decreased libido, etc.
It is about the high probability of somatic manifestations of TDS that every internist should remember. In the end it will correctly interpret the symptoms and help the patient.
As you know, for anxiety disorders of a somatoform nature, such groups of drugs as anxiolytics, antidepressants, antipsychotics are used. β-blockers are prescribed for the treatment of autonomic symptoms: increased sweating, heart palpitations, tremors. Thus, the treatment of somatoform disorders in cardiac patients is usually long-term (at least 1 month), with a gradual transition to a maintenance dose and gradual withdrawal of drugs.
Due to the duration of therapy, as well as taking into account the presence of cardiac comorbidity, prescribed psychotropic drugs should have a high safety profile. Therefore, it is important to choose a drug with an optimal ratio of efficacy and safety, prolonged onset of results, and multidirectional action.
One of these means is the modern drug Lazeya, which has an antidepressant, anxiolytic and mild sedative effect (Table 2). The mechanism of action Silexan ® , which contains linalool and linalyl acetate, is through interaction with voltage-gated calcium channels, mainly of the P- / Q-type. There is evidence that Silexan ® affects the GABA receptors by potentiating the GABA response. Linalool (main component Silexan ® ) interacts with glutamate receptors, glutamate suppresses seizure and its release, and also modulates GABAA receptors.
At the end of her report, Victoria Yuryevna summarized that a modern person can not insure himself against the occurrence of anxiety disorders, especially if he has cardiological pathology. However, the timely treatment of TDS will not only ensure the preservation of the quality of life, but will also serve prevention of other mental disorders, as well as the worsening of the course of cardiovascular disorders. The Danish philosopher Søren Kierkegaard wrote: “I would say that the knowledge of anxiety is an adventure that every person should experience in order not to perish – either from the fact that he does not know anxiety, or from the fact that anxiety will swallow him. Therefore, the one who has learned to worry properly has learned the most important thing. ” Perhaps it is difficult to find a more accurate illustration of the subject of the report.
His view on the management of patients with TDS and autonomic dysfunction presented Head of the Department of reflexology Kharkiv Medical Academy of Postgraduate Education, MD, Professor Olga G. Morozov , noted that the medical problems of the XXI century are quite different from those in previous centuries: at the forefront of disease impaired metabolism, pathological addictions, neurodegenerative diseases, as well as psychosomatic and stress-induced pathology.
Normal body’s response to stress is accompanied – given the release of the stress hormones cortisol and adrenaline, and is the adaptive response, necessary for survival. Anxiety is a universal psychophysiological response to stress. But under conditions of chronic stress, the depletion of neurohormonal and cortical response mechanisms occurs , which leads to sleep disturbances, TDS. Various reasons lead to the appearance of chronic stress in patients: monotony, conflict situations and social tension, information overload, physical inactivity, extraordinary circumstances, inadequacy of requests to opportunities.
Olga Grigorievna emphasized that stress enhances the activity of the hypothalamic-pituitary-adrenal axis with increased release of glucocorticoids, which are physiological inducers of apoptosis. This indicates a direct damaging effect of emotional and affective disorders in the structure of the nervous ICU – threads. Anxiety accompanies most chronic diseases, contributing to their progression and unfavorable course.
A special place in Olga Grigorievna’s report was given to the syndrome of autonomic dysfunction (SVD), which is a kind of manifestation of the imbalance of the sympathetic and parasympathetic structures of the nervous system. SVD leads to disruption of homeostasis and homeokinesis, and is manifested by permanent paroxysmal symptoms. It is believed that SVD is a vegetative-somatic manifestation of anxiety and depressive disorders. One of the most striking and familiar to every practicing physician manifestations of SVD are panic attacks – repeated paroxysms of anxiety in combination with autonomic (somatic) symptoms. In therapeutic practice, they are known as “vegetative crises”. They are characterized by a paroxysmal course, polysystemic autonomic symptoms and emotional-affective disorders.
To stop panic attacks, benzodiazepine drugs are traditionally used once with the subsequent transition to safer drugs for long-term therapy, including the new drug Lazeya with a proven anxiolytic effect. Olga Grigorievna noted that Lazeya is a good alternative to existing anxiolytics, which are used in general medical practice, because: • does not interact with other drugs , including oral contraceptives; • is not addictive; • does not have a sedative effect; • does not affect sexual function; • does not contribute to an increase in body weight; • has a convenient reception – only 1 capsule a day after meals in the evening; • can be used for a long time without withdrawal syndrome.
Also in the context of the problem of imbalance in the structures of the nervous system as the basis of SVD against the background of acute or chronic stress, Olga Grigorievna presented a means for controlling stress – the drug Vitango. It is a plant adaptogen based on the extract of roots and rhizomes of Rhodiola rosea (WS ® 1375, Rosalin ® ). Vitango normalizes the level of stress hormones (norepinephrine, cortisol), reduces anxiety and internal tension. The efficacy of Vitango (Rhodiola rosea extract WS® 1375) has been demonstrated in 13 clinical studies involving 985 patients. In Table 3 presents the fundamental studies on the preparation Vitango (WS ® 1375).
The drug will be useful for patients experiencing chronic stress, fatigue, exhaustion, emotional burnout. Vitango is used 1 tablet 2 r / day before breakfast and lunch (due to the energetic effect, the drug should not be taken in the evening). The drug begins to act from the first day of administration. The maximum effect of the drug is observed after 1 week of administration. Vitango is non -addictive and non- withdrawal. Thanks to its unique double action, it eliminates the symptoms of stress and exhaustion at the same time.
It is impossible not to note that the considered topics you – called a great interest of the audience. The high intellectual level of discussions, a wide range of questions posed to the speakers, the keen interest of doctors in the drugs Lazei and Vitango – all this testified to the relevance of the problem discussed by the specialists.