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Neurotic and Stress-Related Disorders

Author: mugilakil, Posted on Wednesday, November 30 @ 15:58:34 IST by RxPG  

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Psychiatry

Neurotic and Stress-Related Disorders are classified into the following types:

1. Phobic anxiety disorder
2. Other anxiety disorders (called simply anxiety disorder in this book),
3. Obsessive compulsive disorder,
4. Reaction to severe stress, and adjustment disorders,
5. Dissociative (conversion) disorders,
6. Somatoform disorders, and
7. Other neurotic disorders.

Definition of Neurosis

1. The presence of a symptom or group of symptoms which cause subjective distress to the patient
2. The symptom is recognized as undesirable (i.e. insight is present).
3. The personality and behaviour are relatively persevered and not usually grossly disturbed.
4. The contact with reality is preserved.
5. There is an absence of organic causative factors.



ANXIETY DISORDER


Anxiety is a normal phenomenon

Characterized by a state of apprehension or unease arising out of anticipation

Anxiety from fear, as fear is an apprehension in response to an external danger while in anxiety the danger is largely unknown.

Normal becomes pathological
significant subjective distress and / or impairment in functioning of the individual.



Trait anxiety: This is a habitual tendency to be anxious in general and is exemplified by 'I often feel anxious',

State anxiety: This is the anxiety felt at the present moment exemplified by 'I feel anxious now'. Persons with trait anxiety often have episodes of state anxiety,


Symptoms of Anxiety

1. Physical Symptoms

Motoric Symptoms
Tremors, Restlessness, Muscle twitches, Fearful facial expression

B. Autonomic and Visceral Symptoms

Palpitations, Tachycardia, Sweating, Flushes, Dyspnea, Hyperventilation, Dry Mouth, Frequency and hesitancy of micturition, Dizziness, Diarrhea, Mydriasis

2. Psychic Symptoms


A. Cognitive Symptoms

Poor concentration, distractibility, Hypersexual, Vigilance or scanning

B. Perceptual Symptoms

Derealization, Depersonalization

c. Affective Symptoms

Diffuse, unpleasant, vague sense of apprehension, Fearfulness, Inability to relax, irritability, Feeling of impending doom or
(When severe)

d. Other Symptoms

Insomnia (initial) Exaggerated startle response

1. Generalized Anxiety Disorder

insidious onset in the third decade and a stable, chronic course, may or may not be, panic attacks atleast period of 6 months

The one year prevalence of generalized anxiety disorder is 2.5-8%. It is the commonest psychiatric disorder in the general population.

The most important differential diagnosis is from depressive disorders and from organic anxiety disorder.

2. Panic Disorder

This is characterized by discrete episodes of acute anxiety.

Sudden in onset, lasts for a few minutes and is characterized. unexpectedly or 'out-of- the-blue'.

Organic anxiety disorder and cardiac disorders.

MVPS (mitral valve prolapse syndrome). (like panic disorder), prolapse, usually congenital, of the mitral valve into the atrium. The diagnosis is usually established on 'Echo' (echocardiography)

1.5 - 2%/ with 3-4%


Etiology

Is not clearly known. There are many theories of which more than one may be correct.

1. Psychodynamic Theory

Disturbing the internal psychological equilibrium.

Signal anxiety.

repression, a primary defense mechanism.

Secondary defense mechanisms, like conversion, isolation, are called into action.


Primitive anxiety

Signal anxiety.

Panic anxiety
Separation anxiety of childhood.

2. Behavioral Theory

Unconditioned inherent response or the organism to painful or dangerous stimuli

Behavioral approach is more helpful in treatment rather than in explaining the cause of anxiety.

3. Cognitive Behavioral Theory (CBT)

of selective information processing, cognitive distortions, negative automatic thoughts Perception of decreased control over internal external stimuli.


4. Biological Theory (CBT)

i. Genetic evidence

15-20% of the first degree

monozygotic twins 80%

ii Chemically induced anxiety states

Sodium Lactate, Isoproterenol Yohimbine and Inhalation

iii. GABA-benzodiazepine receptors

The type I (w1) is GABA
type II (w2) is GABA and chloride dependent.

GABA (Gamma amino butyric acid)
prevalent inhibitory

iv. Other neurotransmitters

Norepinephrine, 5-HT, dopamine, opioid receptors and neuroendocrine dysfunction

v. Neuroanatomical basis

Locus ceruleus, limbic system,
cortex are some

vi. Organic anxiety disorder

hyperthyroidism, pheochromocytoma, coronary artery disease

Treatment

Tile treatment is usually multi-modal.

1. Psychotherapy

2. Relaxation Techniques

3. Other Behavior Therapies

cognitive behavioral therapy (CBT), biofeedback and hyperventilation control

4. Drug Treatment

pharmacological dissection of anxiety disorders.

generalized anxiety are benzodiazepines, panic, antidepressants.

b-blockers like propranolol

Buspirone

PHOBIC DISORDER

defined as an irrational fear of a specific object, situation or activity, often leading to persistent avoidance of the feared object, situation or activity.

1. Agoraphobia
2. Social phobia, and
3. Specific (Simple) phobia.

1. Agoraphobia

irrational fear of situations
Women outnumber men

open spaces only, now it includes fear of open spaces, public places, crowded places, any other place from where there is no easy escape to a safe place.

Places from where escape may be difficult or help may not be available
develops embarrassing or incapacitating symptoms.

agora-phobia with panic disorder, agoraphobia without panic disorder.

phobic companion(s).


Characteristic Features of Phobia

1. Presence of the fear of an object, situation or activity.
2. The fear is out of proportion to the dangerousness perceived.
3. Patient recognizes the fear as irrational and unjustified (insight is present).
4. Patient is unable to control the fear and is very distressed by it.
5. This leads to persistent avoidance of the particular object, situation or activity.
6. Gradually, the phobia and the phobic object become a reoccupation with the patient, resulting in marked distress and restriction of the freedom of mobility (afraid to encounter the phobic object; phobic avoidance).


2. Social Phobia

irrational fear of activities or social interaction, irrational fear of performing activities in the presence of other people or interacting with others.

There is marked distress and disturbance in daily functioning Examples are fear of blushing (erythrophobia), eating, public speaking, public performance (e.g. on stage), participating in groups, writing in public (e.g.: signing a check), speaking to strangers (e.g. for asking for directions), dating, speaking to authority figures, and urinating in a public lavatory (shy bladder}.

3. Specific (Simple) Phobia

Anticipatory anxiety leads to persistent avoidant behavior, with the avoided object or situation leads to panic attack.

acrophobia (fear of high places), zoophobia (fear of animals), xenophobia (fear of strangers), algophobia (fear of pain), and claustrophobia (fear of closed places).


Course

in women with an onset in late second decade
chronic
phobias are spontaneously remitting.

Etiology

1. Psychodynamic Theory

anxiety
dealt with repression

In phobia
Displacement
avoided in day-to-day activity

2. Behavioral Thrones

Phobia is explained as a conditioned reflex

3. Biological Theories

biological models of panic apply to phobias too

Differentia! Diagnosis

anxiety

Treatment

The treatment approach is usually multi-modal.


1. Psychotherapy

Psychodynamically oriented psychotherapy – not
Supportive psychotherapy is a helpful
Cognitive therapy can be used

2. Behavior Therapy

i. Flooding
ii. Systematic desensitization,
iii. Exposure and response prevention.
iv. Relaxation techniques

3. Drug Treatment

The drugs used in the treatment of phobia are:

i. Benzodiazepines
Alprazolam

ii. Antidepressants, imipramine (TCA) and phenelzine (MAOI),
SSRIs fluoxetine and sertraline


OBSESSIVE-COMPULSIVE DISORDER

obsession

1. idea, impulse or image

2. recognized as one's own idea, impulse or image but is ego-alien (foreign to one’s personality).

3. recognized as irrational and absurd (insight is present).

4. tries to resist against it but is unable to

5. Failure to resist leads, to marked distress.

Differentiation
delusion
Thought insertion

compulsion

1. A form of behavior which usually follows obsessions.
2. It is aimed at either preventing or neutralizing the distress or fear arising out of obsession
3. The behavior is not realistic and is either irrational or excessive,
4. Insight is present, so the patient realizes the irrationality of compulsion,
5. The behavior is performed with a sense of subjective compulsion (urge or impulse to act). Compulsions may diminish the anxiety associated with obsessions.

Epidemiology, Course and Outcome

In India, obsessive compulsive disorder (OCD) is more common in unmarried males, while in other countries no sex differences
upper social strata and with high intelligence.
late third decade (i.e. 20s) in India

Although classical1y thought to have a steady chronic course, the longitudinal profile of this disorder is often episodic.

A 25% remained unimproved over time, 50% had moderate to marked improvement while 25% had recovered completely.

Clinical Syndromes


1. Predominantly obsessive thoughts or ruminations,

2. Predominantly compulsive acts (compulsive rituals), and

3. Mixed obsessional thoughts and acts,

Depression is very commonly
Premorbidly obessional or anankastic personality disorder or 'traits' may be commoner

Four clinical syndromes

1. Washers

obsession is of contamination with dirt, germs, body excretions and the like. The compulsion is washing of hands or the whole body, bathroom, bedroom, door knobs and personal articles gradually.

avoid contamination, washing becomes a ritual.

2. Checkers

multiple doubts, e.g. the door has not been locked, kitchen gas has been left open, counting of money was not exact,
compulsion - checking repeatedly
one doubt has been cleared

3. Pure Obsessions

by repetitive intrusive thoughts, impulses or Images not with compulsive acts
sexual or aggressive in nature
counter-thoughts (e.g. counting) and not by behavioral rituals.

obsessive rumination

4. Primary Obsessive Slowness

severe obsessive ideas and / or extensive compulsive rituals, relative absence of manifested anxiety.

Etiology


1. Psychodynamic Theory

obsessions and phobias to be psychogenetically related.

Isolation of Affect

affect (isolates the affect) from the anxiety-causing idea. neutral ideas are made anxiety-provoking and turned into obsessions.

Undoing

leads to compulsions, which prevent or undo the feared consequences of obsessions.

Reaction formation displacement leads to formation


2. Behavioral Theory

obsessions as conditioned stimuli to anxiety (similar to phobias).
Cornpulsions as learned behavior
decrease in anxiety positively reinforces the compulsive acts and they become stable learned behaviors.

3- Biological Theories

von Economo's encephalitis, basal ganglia lesions, Gilles de la Tourette syndrome, and hypo-thalamic and third ventricle lesions.

ii. 5-7%ofhrst decree relatives

iii. Psychosurgery

iv. central 5-HT system

Some cingulum (gyrus)
probable site of lesion
others temporal lobes

Treatment

1. Psychotherapy

i. Psychoanalytic psychotherapy

ii. Supportive psychotherapy


2. Behavior Therapy

as 80%


i. Thought-stopping (and its modifications),
ii. Response prevention
iii. Systematic desensitization,
iv. Modeling.


3. Drug Treatment

i, Benzodiazepines

ii. Antidepressants : specific serotonin reup-take inhibitors {SSRIs) Clomipramine (75-300 mg/day)

iii. Antipsychotics

iv. Buspirone, Clonazepam

4. Electroconvulsive Therapy

severe depression with obsessive compulsive disorder, ECT may be
Needed.

5. Psychosurgery

i. Stereotactic limbic leucotomy.

ii. Stereotactic subcaudate tractotomy.


DISSOCIATIVE AND CONVERSION DISORDERS

hysteria has various contexts are:

1. Impulsive, uncontrolled behavior (impulse dyscontrol).
2. Manipulative, dramatic, exhibitionistic, emotional and/or seductive behavior (histrionic personality traits).

3. Absence of objective signs of an organicillness.
4. Presence of multiple vague somatic symptoms, especially in a female patient (masked depression, somatization disorder Or Briquet’s hysteria).
5> Hypochondnasis.
6. Any mental illness.
7. Presence of certain symptoms which are not explainable in the context of present organic illness (functional overlav, conversion symptoms).

8. Difficult patient; poor doctor-patient communication,
9. 'Sick' role or 'abnormal illness behavior'.
10. Psychosomatic disorders.
1L Malingering.
12. Psychosexual dysfunctions,

term hysteria has been replaced in ICD-10 by dissociative (conversion) disorders

Epidemiology

Hysteria (comprising of conversion, dissociation and somatization disorder)
6-15% of OPD
14-20% of all neurotic disorders.
Females usually outnumber males, children the percentage is similar in boys and girls.

1. Conversion Disorder

1. Presence of symptoms or deficits affecting motor or sensory function, suggesting a medical or neurological disorder.

2. Sudden onset.

3. Development of symptoms usually in the presence of a significant psychosocial stressor(s).

4. A clear temporal relationship between stressor and development or exacerbation of symptoms,

5. Patient does not intentionally produce symptoms.

6. There is usually a 'secondary gain' (though not required by ICD-10 for diagnosis).

7. Detailed physical examination and investigations do not reveal any abnormality that can explain the symptoms adequately.

8. The symptom may have a ‘symbolic' relationship with the stressor/conflict.

two types motor and sensory


1. Dissociative Motor Disorders

The motor disturbance usually involves
The 'paralysis' - monoplegia, paraplegia or quadriplegia. Examination shows normal or voluntarily increased tone and normal reflexes.

The 'abnormal movements’, gait, gait disturbance {aslasia abasia) is usually characterized by a wide-based, staggering, Jerky, dramatic and irregular gait with exaggerated body movements.


2. Dissociative Anesthesia and Sensory Loss (Sensory Disorders)

sensory disturbance 'glove and stocking anesthesia (absence of all sensations with an abrupt boundary, not confirming with the distribution of derma tomes, and usually limiting at wrists_and ankles), hemianesthesias blindness or contracted visual fields (‘tubular vision’) and deafness.

Sensory disturbances are inconsistent with the anatomic patterns expected. - touch, pain, temperature and position sense, conversion disorder, the loss of vibration, strict midline separation

bilateral conversion blindness is able to go about his way doesn’t injure himself.
unilateral the papillary - affected eye


3. Dissociative Convulsions (Hysterical Fits)

'hysterical fits' or pseudoseizures, convulsive movements and partial loss of consciousness
partial, brief unresponsiveness/ in the absence of convulsive movements (called as brief dissociative stupor or simple dissociative disorder}

2. Dissociative Disorder

1. Disturbance in the normally integrated functions of consciousness, identity and/or
memory. .
2. Onset is usually sudden and the disturbance is usually temporary- Recovery is often abrupt,
3. Often, there is a precipitating stress before the onset. There is a clear temporal relationship between the stressor and the onset of the illness- A frequent stressful situation is an ongoing war.
4. A 'secondary gain' resulting from the development of symptoms may be found.
5. Detailed physical examination and investigations do not reveal any abnormality that can explain the symptoms adequately.

1. Dissociative Amnesia

adolescent and young adults (females more than males, except in war), it is characterized by a sudden inability to recall important personal information (amnesia), particularly concerning stressful or traumatic life events. dissociative amnesia follows a traumatic or stressful life situation- Sometimes, Imagined stressors or expression of 'forbidden'

During the amnesic period, there may be slight clouding of Consciousness.

2. Dissociative Fugue

is characterised by episodes of wandering away (usually from home). adopts a new
identity with complete amnesia for the earlier life. sudden, often in the presence of severe stress.
recovery of memories The characteristic feature is the assumption of a purposeful new identity with absence of awareness of amnesia.

important differentia [diagnosis is from fugue
states seen in'complex partial seizures



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