Classification of neurotic disorders

Question 1

ICD-10

Answer 1

• 7 headings
• phobic anxiety disorders
• anxiety disorders
• OCD
• reaction to severe stress and adjustment disorders
• dissociative disorders (conversion)
• somatoform disorders and other neurotic disorders

Question 2

Generalised Anxiety Disorder

Answer 2

• characterised by prominent tension, excessive worry with generalised free-floating persistent anxiety and feelings of apprehension about everyday events leading to significant stress and functional impairment
• duration of 6 months in ICD10
• 22 physical symptoms of anxiety- must have 4 including at least 1 autonomic arousal symtpoms

Question 3

Panic attack

Answer 3

• discrete episode of intense anxiety

- starts and peaks within 10 minutes and subsides within 20-30 mins

Question 4

Panic disorder

Answer 4

• recurrent panic attacks which are not secondary to substance missuse, medical conditions or another psychiatric disorder
• may be many a day or few a year
• usually accompanied by persistent worry about having another attack, phobic avoidance of situations
• must be present for 1 months
• severe if more than 4 attacks a week in a 4 week period
• for ICD 10, must occur where there is no danger, not confined to known or predictable situations comparative freedom from anxiety symptoms between attacks

Question 5

DSM criteria for panic disorder

Answer 5

• at least one panic attack followed by at least one of the following three features for 1 month or more
  1. anticipation of further attacks
  2. worry about implications
  3. avoidance behaviour

Question 6

Phobic anxiety disorders

Answer 6

• Marks: fear which is out of proportion, cannot be explained, is beyond voluntary control and leads to avoidance
• phobic object is almost always external and not ‘currently dangerous’ to the individual
• if phobic object is internal e.g nosophobia or dysmorphophobia then these conditions are classified under hypochondriasis

Question 7

Agoraphobia

Answer 7

• commonest phobic disorder seen by psychiatrists and is most incapacitating
• more common in women between the ages of 15-35
• lack of immediate escape route or exit is the main cognitive basis for the anxiety
• distance from home, crowding and confinement are key themes
• anticipatory anxiety can start before the feared situation occurs
• can become completely housebound
• may be accompanied by panic attacks

Question 8

Social phobia

Answer 8

• ICD 10 recognises 2 types- discrete type and diffuse type
• DSM- social phobia is a marked and persistent fear of one or more social or performance situations where one gets exposed to unfamiliar people or possible close scrutiny of others

Question 9

Specific phobias

Answer 9

• onset in in childhood
• phobia of animals= 7 years
• blood phobia= 9
• dental phobia=12
• claustrophobia=20
• more common among women
• does not usually fluctuate and remains constant
• being afraid of catching a disease is nosophobia
• for children over 6 months, adult no limit

Question 10

OCD

Answer 10

-characterised by obsessional thinking, compulsive behaviour and associated with marked anxiety and depression
-ICD10- obsessions and compulsions must be:
1. acknowledged to be originating in the mind
2. repetitive and unpleasant
3 at least one must be unsuccessfully resisted
4. carrying out the obsessive thought or compulsive act is not intrinsically pleasurable
-must be present on most days for a period of at least 2 successive weeks

Question 11

Obsessions

Answer 11

• can occur as thoughts, ruminations, doubts, impulses and phobias
• obsessional slowness can occur as a result of obsessiona doubts or compulsive rituals
• checking, washing, fear of contamination, doubting, bodily fears, counting, insistence on symmetry, aggressive thoughts

Question 12

Compulsive hoarding

Answer 12

• may be distinct to OCD
• new to DSM5
• very difficult to treat

Question 13

Acute stress reaction

Answer 13

-usually starts in an hour
-resolution within 8 hours or 48 hours if prolonged
-patient is often dazed and disorientated
ICD 10 diagnosis

Question 14

Acute Stress disorder

Answer 14

• DSM 4-similar to ICD10
• can last 2 days to 4 weeks
• marked anxiety and 3 dissociative symptoms
• must involve intense fear, helplessness or horror

Question 15

Adjustment disorder

Answer 15

• seen in both ICD-10 and DSM 4
• dont meet criteria for PTSD
• psychological reactions arising in relation to adapting to new circumstances and occurs in someone who has been exposed to psychosocial stressor like divorce, separation which is not catastrophic in nature
• usually anxious and depressed
• must be within 1 month for ICD10 or 3 months for DSM 4
• cannot exceed 6 months apart from prolonged depressive reaction
• gradual onset

Question 16

Bereavement and grief reaction

Answer 16

Patients who experience bereavement within the past 3 months cannot have an adjustment disorder

• normal bereavement is coded in XXI not V
• normal bereavement- hallucinations of widowhood, disbelief, shock, numbness, anger, guiltm sadness, pining, searching
• normal grief reaction lasts up to 12 months with an average duration of 6 months

Question 17

Stages of Grief

Answer 17

Phase 1- shock and protest ( numbness, disbelief and acute dysphoria
Phase 2-preoccupation (yearning, searching, anger)
Phase 3- disorganisation (despair and acceptance of loss)
Phase 4- resolution (gradual return to normality)

Question 18

Abnormal grief

Answer 18

-very intense, prolonged, delayed or absent or where symptoms beyond the normal range are seen
-In ICD10 these are coded in adjustment disordes
Inhibited grief-absence of expected grief symptoms at any stage
Delayed grief- avoidance of painful symptoms within the two weeks of loss
Chronic grief- continued significant grief-related symptoms 6 months after loss
-often caused by unexpected deeath, insecure survivor, dependent or ambivalent relationship with the deceased, presence of dependent children and so cannot show grief easily. Presence of previous psychiatric disorder in the survivor

Question 19

PTSD

Answer 19

• intense prolonged and sometimes delayed reaction to an intensely stressful event
• essential features are hyperarousal, re-experiencing of aspects of the stressful event and avoidance reminders
• Hyperarousal, Hypervigilance and Avoidance
• Both ICD-10 and DSM4 require 2 or more persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor) to diagnose PTSD
• should start within 6 months of the trauma

Question 20

Type 1 trauma

Answer 20

Single sudden catastrophic event

Question 21

Type 2 trauma

Answer 21

Chronic repetitive insult against which the individual has no defence (e.g abuse)

Question 22

Dissociative (conversion disorders)

Answer 22

• dissociation is referred to as loss of integration among memories, identity, sensations and movements
• occurs closely in time with trauma
• starts suddenly and terminated abruptly within weeks and months

Question 23

Dissociative amnesia

Answer 23

• centered on the loss of memory for important recent events which is partial, patchy and selective
• retrograde only, no anterograde deficits
• complete inability of memories which were fenerally formed and previously accessible

Question 24

Dissociative fugue

Answer 24

• purposeful journey away from home occurs. Self care is sually maintained
• sometimes new identity can be assumed
• amnesia is present for past identity during fugue
• there is no cognitve impairment and haviour is normal
• perplexity and la belle indifference are frequent

Question 25

Trance

Answer 25

- dissociative state where narrowed consciousness and limited but repeated movements are seen - only if involuntary and not culturally appropriate - must be intrusive on activities of life and occur outside culturally sanctioned situations - TLE and head injury can cause organic trance

Question 26

Conversion/hysterical disorder

Answer 26

- dissociative disorder of motor moevment and sensation - belle indifference is common - close friends or relatives might have had the actual organic illness whose symptoms are present in a subject with conversion disorder - milder and transient variety is seen in adolescent girls

Question 27

Seizures and pseudoseizures

Answer 27

- avoidance behaviour during seizure to prevent serious injuries - change in symptomatology of seizure patterns - closing eyes during seizures and resisting opening of eyelids - dystonic posturing - emotional or situational trigger for the seizures - gradual onset and cessation of seizures - tongue biting is rare- if happens it is the tip not the side - pelvic movements (especially forward thrusting) and side-to-side head movements - prolonged-2-3 mins, high seizure frequency but no injury - lack of concern or exaggerated emotional response - multiple unexplained physical symptoms - non-response to antiepileptic drugs - seizures that only occur in the presence of others or only when alone

Question 28

Somatisation disorder

Answer 28

a) at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found b) persistent refusal to accept the advise or several doctors regarding the absence of a physical illness c) notable impairment of social and family functioning due to symptoms and the illnesss behaviour aka Briquet Syndrome or St Louis Hysteria -family history of alcohol use and antisocial personality are common in women with somatisation disorder

Question 29

Hypochondriacal disorder

Answer 29

-characterised by 2 conditions 1. persistent belief of harbouring at least one serious physical illness even though repeated investigations and examinations have identified none or persistent preoccupation with a presumed deformity or disfigurement 2. persistent refusal to accept the advice and reassurance of several doctors regarding the absence of a serious illness Nosophobia (serious illness fear) and nondelusional dysmorphophobia are hypochondriasis in ICD10 -6 months required -patient looks for diagnosis not symptom relief -equal in sexes -they will often name the condition

Question 30

Body dysmorphic disorder

Answer 30

- considered a separate diagnostic entity in DSM4 - subjective description of ugliness and physical defect which the patient feels is noticeable to others - it is an overvalued idea about trivial or non-existent physical abnormalities which are perceived as deformities - if delusional intensity then delusional disorder - skin most common, nose , ears, eyes, mouth, buttocks, penis, breasts.. - lots of re-examining, repeated checking, grooming rituals - usually begins in adolescence - chronic with some fluctuations over time - equal in both sexes

Question 31

Somatoform autonomic syndrome

Answer 31

-refers to recurrent symptoms of autonomic arousal, such as palpitations, sweating, tremor, flushing which often occur alongside other subjective symptoms referred to a specific organ or system despite having no evidence of structural or functional deficit in these symptoms

Question 32

Somatoform pain syndrome

Answer 32

-major complaint is of persistent severe and distressing pain that is not explained by a physiological process or a physical disorder

Question 33

Neurasthenia

Answer 33

F48 of ICD10-other neurotic disorder (as well as other culture bound syndromes) - persistent and distressing complaints of increased fatigue after mental effort or persistent and distressing complaints of bodily weakness and exhaustion after minimal effort - depression must not be a feature - CFS!

Question 34

Depersonalisation-derealisation syndrome

Answer 34

-where either depersonalisation or derealisation symptoms are present in the presence of full insight and clear sensorium