Neurosis Flashcards
What is meant by neurosis?
A collective term for psychiatric disorders characterised by distress, that are non- organic, have a discrete onset and where hallucinations and delusions are absent.
What is anxiety?
Unpleasant emotional state involving subjective fear and somatic symptoms
What’s the Yerkes Dodson Law?
This states that anxiety is beneficial up to a plateau of optimal functioning. Beyond this level of anxiety then performance deteriorates.
What are the symptoms of anxiety?
Psychological- anticipatory fear of impeding doom, worrying thoughts, exaggerated startle response, restlessness, poor concentration and attention, irritability, depersonalisation and de realisation.
Cardiovascular- chest pain and palpitations
Respiratory- hyperventilation, cough, chest tightness
GI- abdo pain, loose stools, N and V, dysphagia, dry mouth
Genitourinary- increased freq of micturition, failure of erection, menstrual discomfort
Neuromuscular- tremor, myalgia, headache, parasthesia, tinnitus
What is the ICD-10 classification of anxiety disorders?
Phobic anxiety disorders- agoraphobia, social phobia, specific phobia
Other anxiety disorder- panic disorder, generalised anxiety disorder, mixed anxiety and depressive disorder.
Reaction to severe stress and adjustment disorders- acute stress reaction, post traumatic stress disorder, adjustment disorder.
What are the clinical features of neuroses?
The previous symptoms mentioned
Associated cognitions- worried or fears that are inappropriate or excessive
Associated behaviours include avoidance of escape
Depressive symptoms are also common in neuroses
What are the phobic anxiety disorder?
Specific phobia, agoraphobia, social phobia.
What is generalised (free floating) anxiety?
Present most of the time and not associated with specific objects or situations. Excessive or inappropriate worry about normal life events. Typically longer duration (days, months or even years).
What is episodic (paroxysmal anxiety) ?
Has an abrupt onset, occurs in discrete episodes. The episode of anxiety is severe with strong autonomic symptoms, but usually short lived (typically less than one hour). Can occur in response to specific threats.
What are the common medical conditions associated with anxiety?
Hyperthyroidism, hypoglycaemia, anaemia, phaeochromocytoma, cushings disease, obstructive pulmonary disease (COPD), CCF, malignancies.
What are the psychiatric conditions related to anxiety?
Eating disorders Somatoform disorders Depression Schizophrenia OCD PTSD Adjustment disorder Anxious (avoidant personality disorder)
What are the substance related conditions associated with anxiety?
Intoxication- alcohol, cannabis, caffeine
Withdrawal- alcohol, benzodiazepine, caffeine
Side effects- thyroxine, steroids, adrenaline
What is GAD?
Ongoing, uncontrollable widespread worry about many events or thoughts that the patient recognises as excessive and inappropriate. Symptoms must be present most days and for at least 6 months duration.m
What are the predisposing, precipitating and perpetuating risk factors for GAD?
Predisposing: genetics, childhood upbringing, personality type and demands for high achievement, being divorced, living alone or as a single parent. Low socioeconomic status.
Precipitating: domestic violence, unemployment, relationship problems and personal illness (chronic pain, arthritis, COPD)
Perpetuating: continuous stressful life events.
What are the clinical features of anxiety?
Worry which is excessive and uncontrollable Autonomic hyperactivity (sweating, increase in HR, increase in pupil size) Tension in muscles/ tremor Concentration difficulty/ chronic aches Headaches, hyperventilation Energy loss Restlessness Startled easily/ sleep disturbance
What is the ICD-10 criteria for GAD?
A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems.
At least four of the watcher symptoms and at least one autonomic arousal (palpitations, sweating, shaking/tremor, dry mouth)
What are the investigations would you do for generalised anxiety?
Blood tests- FBC (infection/Anaemia), TFTS (hyperthyroidism), glucose (hypoglycaemia)
ECG- sinus tachycardia
Questionares- GAD 2, GAD7, Becks anxiety inventory, hospital anxiety and depression scale.
What are the differentials for GAD?
Other neurotic disorders: Panic disorder, specific phobias, OCD, PTSD
Depression
Schizophrenia
Personality disorder (anxious PD, dependent PD)
Excessive caffeine or alcohol consumption
Withdrawal from drugs
Organic- anaemia, hyperthyroidism, hypoglycaemia
What is the biological treatment for GAD?
SSRI (sertraline) is recommended which has anxiolytics effects
If the SSRI does not work then SNRI (venlafaxine, duloxetine) can be offered.
If both of the above can’t be tolerated then pregabalin may be used.
Meds should be continued for at least a year.
Why shouldn’t benzodiazepines be used long term for GAD?
They can cause dependence.
What are the psychological treatments of GAD?
Psycho educational groups (low intensity)
CBT and applied relaxation (high intensity)
What are the social intervention management for GAD?
Self help methods- writing things down and analysing them and support groups. Exercise may also help
What is the stepped care model proposed by NICE to determine the most effective interventions for patients with GAD?
Step 1= identification and Assessment. Psycho education about GAD and active monitoring.
Step 2= low intensity psychological interventions
Step 3= high intensity psychological interventions (CBT or drug treatment)
Step 4= highly specialist input (combination of drug and psychological therapies, involvement of crisis team, multi agency teams).
What is meant by phobia?
An intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable.
What is agoraphobia?
A fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack.
What is social phobia (social anxiety disorder)?
A fear of social situations which could lead to humiliation, criticism or embarrassment.
What is a specific (isolated) phobia?
A fear restricted to a specific object or situation.
What are the risk factors for phobias?
Aversive experiences Stress and negative life events Other anxiety disorders Mood disorders Substance misuse disorders Family history
What are the clinical features of phobic anxiety disorders?
Biological- tachycardia is the most common autonomic response, however in phobias of blood, injection and injury then bradycardia can be produced.
Psychological- unpleasant anticipatory anxiety, inability to relax, urge to avoid the feared situation, and at extremes a fear of dying.
What is the ICD-10 criteria of agoraphobia?
A. Marked and consistently manifest fear in, or avoidance of, at least two of the following…
- Crowds
- Public spaces
- Travelling alone
- Travelling away from home
B. Symptoms of anxiety in the feared situation, with at least two symptoms present together (and at least one symptom of autonomic arousal)
C. Significant emotional distress due to avoidance or anxiety symptoms. Recognised as excessive or unreasonable
D. Symptoms restricted to (or predominate in) feared situation.
What is the ICD-10 criteria of social phobia?
A. Marked fear/ avoidance of being the centre of attention or fear of acting in a way that will be embarrassing or humiliating.
B. At least two symptoms of anxiety in the feared situation, plus one of the following…
. Blushing
. Fear of vomiting
. Urgency or fear of micturition/defecation
C. Significant emotional distress due to the avoidance of anxiety symptoms
D. Recognised as excessive or unreasonable
E. Symptoms restricted to (or predominate in) feared situation.
What is the ICD-10 criteria for a specific phobia?
A. Marked fear (or avoidance) of a specific object or situation that is not agoraphobia or social phobia.m
B. Symptoms of anxiety in the feared situation
C. Significant emotional distress due to the avoidance or anxiety symptoms. Recognised as excessive or unreasonable.
D. Symptoms restricted to the feared situations.
What is the management of agoraphobia?
CBT- graduated exposure techniques
SSRIS are the first line pharmacological agent
What is the management of social phobia?
CBT (individual or group) specifically designed for social phobia, graduated exposure
Pharmacological interventions- SSRIs, SNRIs (venlafaxine), or if no response to these, MAOI (moclobemide)
Physcodynamic psychotherapy for those who decline CBT or medication.
What is the management of specific phobia?
The mainstay of treatment is exposure either using self help methods or more formally though CBT.
What is panic disorder?
Characterised by recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.
What are the most heritable anxiety disorder?
OCD and panic disorder.
What are the aetiologie of panic disorder?
Genetics
Neurochemical: post synaptic hypersensitivity to serotonin and adrenaline
Sympathetic nervous system- fear or worry stimulates the SNS which can increase cardiac output and lead to further anxiety
Cognitive- misinterpretation of somatic symptoms eg: fear that palpitations will lead to heart attack
Environmental- presence of life stressors can lead to panic disorder
What are the risk factors for panic disorder?
Family history Major life events 20-30 years Recent trauma Females Other mental disorders White ethnicity Asthma Cigarette smoking Medications eg: benzodiazepine withdrawal
What is the ICD-10 criteria for the diagnosis of panic disorder?
A. Recurrent panic attacks that are not consistently associated with a specific situation or object and often occur spontaneously.
The panic attacks are not associated with marked exertion or with exposure to dangerous or life threatening situations.
B. Characterised by all of the following
Discrete episode of intense fear or discomfort
Starts abruptly
Reaches a crescendo within a few minutes and lasts at least some minutes
At least one symptom of autonomic arousal
Palpitations
Sweating
Shaking
Tremor
Dry mouth
What are the features of panic disorder?
PANICD
P= palpitations A= abdominal distress N= numbness/ nausea I= intense fear of death C= choking/chest pain S= sweating/ shaking/ shortness of breath D= depersonalisation/ derealization
What is the difference between depersonalisation and derealisation?
Depersonalisation- feeling disconnected or detached from one’s self
Derealization- mental state where you feel detached from your surroundings
What is the management of panic disorders?
SSRIs are first line but they are not suitable or there is no improvement after 12 weeks, then a TCA eg: imipramine or clomipramine may be considered.
CBT
Self help methods including bibliotherapy, support groups and encouraging exercise to promote good health
What is PTSD?
An intense, prolonged, delayed response to an exceptionally traumatic event.
What is abnormal bereavement?
Has a delayed onset, is more intense and prolonged (>6months). The impact of their loss overwhelms the individuals coping capacity.
What is an acute stress reaction?
An abnormal reaction to sudden stressful events.
What is adjustment disorder?
Significant distress (greater than expected), accompanied by an impairment in social functioning when adapting to new circumstances.
What is the most important component of aetiology of PTSD?
An exceptionally stressful event in which the individual was involved directly or as a witness.
What are the risk factors of PTSD…
Exposure to a major traumatic event - certain professions
Pre trauma: previous trauma, history of mental illness, females, low socioeconomic economic background, childhood abuse
Peri trauma: severity of trauma, perceived threat to life, adverse emotional reaction during or immediately after an event.
Post trauma: concurrent life stressors, absence of social support.
What are the symptoms of PTSD?
PTSD symptoms must occur within 6 months of the event and can be divided into four categories…
1. Reliving
- Avoidance
- Hyperarousal
- Emotional numbing
What is the ICD-10 criteria for the diagnosis of PTSD?
A- Exposure to a stressful event
B- Persistent remembering ‘reliving off the situation’
C- Actual or preferred avoidance of similar situations which either resemble or are associated with the stressor
D- Either (1) or (2):
- Inability to recall some important aspects of the period of exposure to the stressor
- Persistent symptoms of increased psychological sensitivity and arousal
Criteria B, C and D all occur within 6 months of the stressful event, or the end of a period of stress.
What questionares can be used to screen for PTSD?
Trauma Screening Questionare
Post traumatic diagnostic scale
What are the stages of grief?
DABDA Denial Anger Bargaining Depression Acceptance
What is an acute stress disorder?
Exposure to an exception, physical or mental stressor followed by an immediate onset of symptoms (within one hour). It is divided into mild, mod, severe, based on the symptoms. Symptoms should diminish within 8 hours if it is an immediate stressor or 48 hours if it is a transient stressor.
What is adjustment disorder?
Identifiable (non catastrophic) psychosocial stressors like redundancy and divorce within one month of onset of symptoms. Symptoms must be less than 6 months.
What is the management of PTSD?
. Psychological intervention- CBT and eye movement desensitisation and reprocessing (EMDR)
. SSRI= Paroxetine (weaker), atypical= mirtazapine, amitriptyline, phenelzine are licensed however amitriptyline and phenelzine are rarely used due to the side effects.
What is obsessive compulsive disorder?
It is characterised by recurrent obsessional thoughts or compulsive acts, or commonly both.
What is meant by an obsession?
UNWANTED INTRUSIVE thoughts, images or urges that repeatedly enter the individuals mind. They are distressing for the individual who attempts to resist them and recognises them as absurd.
What are compulsions?
Repetitive, stereotyped behaviours or mental act that a person feels driven into performing.
What is meant by covert and overt compulsions?
Covert- things you can’t see
Overt- observable by others
What is the pathophysiology/aetiology of OCD?
Biological: related to decreased serotonin and abnormalities of the frontal cortex and basal ganglia
Psychoanalytic’s- filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness.
Behavioural- compulsive behaviour is learned and maintained by operant conditions.
What are the risk factors for OCD?
More common in the relatives of OCD patients
Carrying out the compulsive act is a maintaining factor
Developmental factors- abuse, neglect, bullying, social isolation
What are features of obsessions and compulsions. (FordcaR)
F= failure to resist O= originate from the patients mind R= repetitive and distressing C= carrying out the obsessive thought (or compulsive act) is not in itself pleasurable, but does reduce anxiety levels.
What is an OCD cycle?
Obsessions create anxiety which continue to build until a compulsion is carried out in order to provide relief.
What is the questionare used for OCD?
Yale Brown obsessive compulsive scale
What is the management for OCD?
CBT
SSRIs are the drug of choice, NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
Clomipramine can be added to citalopram in more severe cases.
Alternatively an antipsychotic can be asses in with an SSRI or clomipramine
What is a somatoform disorder?
Group of disorders where the physical symptoms are caused by mental or emotional factors.
What are dissociative (conversion) disorders?
Characterised by symptoms which cannot be explained by a medical disorder and where there are convincing associations between a stressful event and symptoms.
What is the pathophysiology of somatoform disorders?
Biological- possible implication of neuro endocrine genes. Studies show a genetic component
Psychological- a high proportion of those with PTSD suffer from somatoform disorders
There is an association between somatization and physical or sexual abuse
Social- adopting of the sick role in order to release stress
What is somatisation disorder?
This is also known as briquets syndrome
It is multiple, recurrent and frequently changing physical symptoms which are not explained by a physical illness.
What are the features of somatization disorder?
At least 2 years duration
Preoccupation with symptoms causing physical distress leading them to seeking repeated consultations and requesting investigations
Continuous refusal to accept reassurance that there is no causes for their symptoms
Total of 6 or more symptoms
What symptoms do people with somatoform disorder present with?
GI: abdo pain, N&V, bloating, regurgitation, loose bowels, difficulty swallowing
CVS: chest pain, breathlessness, palpitations
Genitourinary- dysuria, frequency, incontinence, vaginal discharge, menstrual problems
What is somatisation disorder?
This is also known as briquets syndrome
It is multiple, recurrent and frequently changing physical symptoms which are not explained by a physical illness.
What are the features of somatization disorder?
At least 2 years duration
Preoccupation with symptoms causing physical distress leading them to seeking repeated consultations and requesting investigations
Continuous refusal to accept reassurance that there is no causes for their symptoms
Total of 6 or more symptoms
What symptoms do people with somatoform disorder present with?
GI: abdo pain, N&V, bloating, regurgitation, loose bowels, difficulty swallowing
CVS: chest pain, breathlessness, palpitations
Genitourinary- dysuria, frequency, incontinence, vaginal discharge, menstrual problems
What is hypochondriacal disorder?
This is where patients misinterpret normal bodily sensations which leads them to non delusional pre occupation that they have a serious physical disease ie: cancer.
What is dysmorphophobia?
This is also known as body dysmorphic disorder, it is where there is excessive preoccupation with a barely noticeable or imagined defect in their physical appearance. The pre occupation causes significant distress.
What is somatoform autonomic dysfunction?
This is where symptoms are related to the autonomic nervous system, symptoms of autonomic arousal are attributed by patients to a physical disorder of one or more of the CVS, resp, GI, genitourinary.
What is persistent somatoform pain disorder?
Persistent (6 months) and severe pain that cannot be fully explained by a physical disorder
The pain usually occurs as a result of psychosocial stressors and emotional difficulties.
It differs from somatization in that pain is the primary feature and multiple symptoms from different systems are not present.
What is hypochondriacal disorder?
This is where patients misinterpret normal bodily sensations which leads them to non delusional pre occupation that they have a serious physical disease ie: cancer.
What is dysmorphophobia?
This is also known as body dysmorphic disorder, it is where there is excessive preoccupation with a barely noticeable or imagined defect in their physical appearance. The pre occupation causes significant distress.
What is somatoform autonomic dysfunction?
This is where symptoms are related to the autonomic nervous system, symptoms of autonomic arousal are attributed by patients to a physical disorder of one or more of the CVS, resp, GI, genitourinary.
What is persistent somatoform pain disorder?
Persistent (6 months) and severe pain that cannot be fully explained by a physical disorder
The pain usually occurs as a result of psychosocial stressors and emotional difficulties.
It differs from somatization in that pain is the primary feature and multiple symptoms from different systems are not present.
What are the differential diagnoses of somatoform disorders?
Dissociative
Factitious disorder
Malingering
Multi systemic disease
What is the management of somatoform disorders?
Biological therapies: antidepressants SSRIs
Psychological therapies: CBT
Social: can get family involved, encourage exercise, stress relief activities.
