Neurotic, Stress-related And Somatoform Dis

Symptoms

Psychosis

Neurosis

Hallucinations

+

-

Delusions

+

-

Thought disorder

+

-

Reality testing

Impaired

Intact

Insight

Impaired

Retained

Neurotic, stress-related and somatoform disorders Symptom or group of symptoms Behaviour greatly effected but socially acceptable Insight and reality testing retained Personality not disorganised

Epidemiology Prevalence     

Age group 25-44 Life time 40% Mean number 2.1 General practice 9% Mixed anx & dep 80%

Life events risk  Vulnerability factors  Long term difficulties  Provoking factor

Socioeconomic status  Lower social class & educational status  Urban areas

Marriage  Protective factor for males

Childhood behaviour & neurosis  No relation with neurosis  Conduct disorder related to antisocial personality dis

Mortality  Higher 1.5 times  Risk of suicide & substance abuse

Outcome after one year  25% improve  50% variable course  25% deteriorate

Generalised anxiety disorder Disproportional to threat or more prolonged

Clinical features

Psychological  

Worrying thoughts Fearful anticipation

Somatic (3) Gastrointestinal • •

Dry mouth Difficulty swallowing

Respiratory • Hyperventilation • Difficulty breathing Cardiovascular • Palpitations • Chest oppression

Genitourinary • •

Frequency of micturition Erectile difficulty

Neuromuscular • •

Tremor Aches & pains

Sleep disturbances • •

Early insomnia Night terrors

Co morbidity (60%) • •

Phobic or depressed Substance abuse

Panic disorder Recurrent attacks of severe anxiety not restricted to any situation Biological basis • •

• •

Biochemical: Sodium lactate & carbon dioxide induce attacks First degree relatives X 4 times ↑ bf right parahippocampal area Neurotransmitter abnormalities: NA, 5HT, GABA

Clinical features Psychological: • Overwhelming fear of dying/losing control/going mad Somatic: • Dyspnoea/chest oppression/dizziness • Sweating/palpitation/flushing/trembling • Nausea/abdominal discomfort

Co morbidity (90%) • •

Anxiety & depression Substance abuse

Prognosis • • •

30% recover 50% recurrences, symptoms mild 20% chronic

Agoraphobia Multiple phobic symptoms with high levels of anxiety Epidemiology

Commonest phobic disorder 75% females Premorbid dependency traits 50% have history of panic disorder

Clinical features Fear • Leaving home • Being alone • Being trapped

Anxious thoughts (fainting & losing control)

Avoidance • Crowds • Public transport • Confinement • Cinemas/theatres Anticipatory anxiety

Prognosis •

H/O panic disorder better outcome

•

Duration > 6 months prolonged fluctuating course

Obsessive compulsive disorder Recurrent thoughts, impulses, or images despite efforts to exclude them Prevalence 2%, slightly more common in females Premorbid personality OCPD in one third OCPD leads to depression more often

Thoughts • • •

Intrude against will Recognised as own but senseless Are resisted

Content • • • •

Contamination Pathological doubt Symmetry Sexual &Aggressive

Ruminations • •

Repetitive inconclusive thoughts “Meaning of life”

Images • •

Inside head Sexual, aggressive nature

Compulsions (Obsessional rituals) • • •

Checking Washing Restricted to one place in one third

Anxiety & depression common Organic basis • • •

Increased bf orbito frontal cortex Small size caudate nucleus 5HT receptors supersensitive

Associated with • • • •

Encephalitis lethargica Sydenham’s chorea Tourette syndrome Brain trauma

Secondary to • • •

Depression 30% Anorexia nervosa Somatoform disorders

Anxiety disorders Management

Differential diagnosis Generalised anxiety disorder

Drugs

Physical illnesses • Thyrotoxicosis • Phaeochromocytoma • Hypoglycaemia Substance abuse • Alcohol withdrawal • Amphetamine & cocaine abuse • Excessive use of caffeine

Benzodiazepines Alprazolam 0.25mg BD SSRI’s Fluoxetine 20mg/D Tricyclic Antidepressants

Phobic anxiety • Ischaemic heart disease • Paranoid & psychotic states • Post traumatic stress disorder • Depression • Personality disorders (Avoidant, schizoid, & paranoid)

MAOI’s B-Blockers Azapirone

Imipramine 150mg/D Clomipramine 150mg/D Moclobemide 300mg/D Propanolol 20mg BD Buspirone 5mg TDS

Behavior therapy • • •

Desensitisation Relaxation therapy Exposure & response prevention

Cognitive psychotherapy

Somatoform disorders Physical symptoms

Dissociative disorders

(Hysteria) Females 10 times more, lower socio educational background Stress related; physical symptom without corresponding pathology Symptoms:

Dissociative amnesia

• •

• •

blindness, deafness, tunnel vision Aphonia, seizures, paralysis

Associated features • • •

Primary & secondary gain La belle indifference identification

90% recover; 25% develop CNS disease

• •

Sudden onset Circumscribed personal memory loss

Dissociative fugue state • •

Wandering in amnesic state Behaviour purposeful (new identity)

Dissociative stupor Motionless for hours Muscle tone normal

Exclude organicity, alcohol, or substance abuse, epilepsy

Somatoform disorders (Types)

Somatisation disorder • • •

• • • • •

More common in females 20% 1st degree relatives; F/H antisocial personality disorder & alcoholism Multiple physical complaints Chest/cardiac Back/joint pains Menstrual symptoms Mood swings/irritability Dramatic & inconsistent histories Seek immediate relief Extensively investigated & treated Runs chronic course

Hypochondriasis • • • • • •

•

Equally common both sexes No familial aggregation Preoccupation with having serious and progressive disease Common regions: head, neck, abdomen May have obsessional & phobic quality but no resistance or avoidance May be secondary to: Depression Anxiety Psychosis Seek reassurance & investigations

Somatoform disorders Treatment

Aetiology Psychoanalytic theory •

•

Conflict between threatening ideas and impulses results in anxiety which gets converted into symptoms (primary gain) Care & sympathy received constitutes secondary gain

Sociological theory • •

Sick role exempts from social obligations Illness behaviour is determined by patient’s ethnic, cultural, and educational background

•

Do not confront

•

Impossible to make distinction between cons/uncons origin

•

Examine and investigate with minimum fuss

• •

Reassure Minimise secondary gains

• •

Reward symptom-free periods Allow discard symptoms without losing self-esteem Abreaction

•

Defence mechanisms Automatic psychological measures Used universally & not limited to psychiatric disorders Indicate both health & disease Repression: Thoughts & feelings unacceptable to consciousness are thrust back into unconscious Denial: Automatic distortion of outer reality Projection: Attribute disowned & ascribed to somebody else Reaction formation: Developing opposite to the one being defended against

Displacement: Transfer of affect, usually anger or fear, from one person to another Rationalisation: Justifying reasoning after the event Undoing: Acts carried out to cancel out the previous act Regression: Reversal to earlier modes of functioning Turning against the self: Deflection of hostile & disadvantageous behaviour towards self Sublimation: Harmful urges given socially acceptable expression Compensation: Development of abilities to conceal defect

Grief reaction Abnormal grief • • •

More intense Onset delayed Lasting > 6 months

Risk factors Sudden, horror deaths Ambivalent, dependent relationships

Features Denial Pseudo hallucinations & illusions Anxiety & depressive features Identification symptoms

Treatment Address deceased in past tense Discuss last days before death Visit grave Symptomatic treatment for depression

Stress related disorders Stress

Acute stress reaction Stress: Overwhelming threat Helplessness & horror

Clinical features •

• • • •

Dissociative symptoms Numbness Disorientation Impaired cognition Autonomic arousal Purposeless over activity or stupor Begins immediately & lasts up to 3 days Occurs in 25% of those exposed

Treatment: Psychotherapy

Natural

Man made

Bereavement War Earthquakes Rape Acute stress reaction Floods Planedis crash Post traumatic stress Adjustment dis

Adjustment disorders Emotional or behavioural symptoms occurring within 1-3 moths of stressor

Adjustment disorders

Depressed mood, anxiety, worry, irritability Significant social, academic, occupational functioning

Bereavement

Relationship

Role change

Work change

Treated with psychotherapy

•Problem solving approach Physical illness • Break defences (anger & guilt) • Recognise displacement of anger

Retirement

Symptomatic treatment to lower anxiety

Post traumatic stress disorder Stress exceptionally threatening Latency period lasting weeks to months Epidemiology • •

5-10% general population; twice in females 30% trauma victims; up to 300,000 US troops fighting in Iraq & Afghanistan

Predisposing factors • • • • •

Childhood trauma Lower social class Young & elderly Personality disorders History of psychiatric disorder

Biological changes • •

Structural damage to amygdale & hippocampus HPA dysfunction, 5 HT, and opioid system

Clinical features Hyperarousal, hypervigilance, insomnia Repeated reliving the trauma Flashbacks  Vivid nightmares  Avoidance & Dissociative symptoms • Emotional numbness (blunting) • Depersonalisation • Avoidance of reminders Maladaptive coping  Persistent anger  Drug abuse  Suicidal attempts Anxiety & depression

Treatment Cognitive behaviour therapy SSRI’s

Gulf war syndrome • Quarter (175,000) of US & 6000 of British troops (55,000) • Two chemicals implicated • •

Pyridostigmine: protect against nerve gas Pesticides: used to protect against sand flies

Symptoms •

↓ Memory & con

• •

Persistent headaches Fatigue

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Widespread pain

•

Chronic digestive & respiratory symptoms

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Skin rashes