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
•
Widespread pain
•
Chronic digestive & respiratory symptoms
•
Skin rashes