Neurotic Disorders Flashcards
What is neurosis?
Collective term
Psychiatric disorders characterised by distress, are non-organic, have a discrete onset
Delusions and hallucinations absent
What is anxiety?
Unpleasant emotional state
Involves subjective fear and somatic symptoms
What is Perkes-Dodson law?
Anxiety can actually be beneficial up to a plateau of optimal functioning, beyond this level performance deteriorates
What are the common symptoms of neuroses?
Psychological - impending doom, worry, restlessness, poor concentration, irritability, depersonalisation, derealisation
CV - palpitations, chest pain
Resp - hyperventilation, cough, chest tightness
GI - abdo pain, butterflies, loose stools, nausea, vomiting, dysphagia, dry mouth
Genitourinary - increase freq of micturition, failure of erection, menstrual discomfort
Neuromuscular - tremor, myalgia, headache, paraesthesia, tinnitus
What is the ICD-10 classification of neurotic and stress-related disorders?
Phobic anxiety - agoraphobia with or without panic disorder, social phobia, specific phobia
Other anxiety disorders - panic disorder, GAD, mixed anxiety and depressive disorder/
Obsessive compulsive disorder - predominantly obsessive or predominantly compulsive, or mixed
Reaction to severe stress and adjustment disorders - acute stress reaction, PTSD, adjustment disorder
What are the clinical features of neuroses?
Common symptoms that can feature in any anxiety disorder
Associated cognitions e.g. worries or fears that are inappropriate or excessive
Associated behaviours include avoidance or escape
DEPRESSIVE SYMPTOMS
What is the classification of neuroses?
Paroxysmal anxiety - situation dependent; phobic anxiety, or situation independent; panic disorder.
Continuous anxiety - GAD
What are the features of generalised free-floating anxiety?
Present most of the time
Not associated with specific objects or siutations
Excessive or inappropriate worry about normal life events
Typically longer duration - days, months, years
What are the features of episodic anxiety?
Abrupt onset
Occurs in discrete episodes
Episode of anxiety is severe, strong autonomic symptoms, short lived less than 1 hour
What conditions can commonly be seen with anxiety?
Medical - hyperthyroidism, hypoglycaemia, anaemia, Cushing’s, COPD, CCF, malignancies
Substance related
Intoxication - alcohol, cannabis, caffeine
Withdrawal - alcohol, benzos, caffeine
Side effects - thyroxine, steroids, adrenaline
Psychiatric - EDs, somatoform disorders, depression, schizophrenia, OCD, PTSD, adjustment disorder, personality disorder
What is the definition of GAD?
Syndrome of ongoing, uncontrollable widespread worry about many events or thoughts, that the patient recognises as excessive or inappropriate.
Must be present on most days for at least 6 months
What is the aetiology of GAD?
Biological - genetic if FH, or neurophysiological - dysfunction of autonomic nervous system, exaggerated responses in amygdala and hippocampus, alterations in GABA, serotonin and NA.
Environmental - stressful life events, child abuse, problems with relationships, personal illness, employment of financial issues.
or substance dependence or exposure to organic solvents.
What are the risk factors for GAD?
Predisposing - genetics, childhood, personality type, demands for high achievement, divorced, living alone
Precipitating - stressful life events, domestic violence, relationship problems, illness
Maintaining - continuing stressful events, marital status, living alone, ways of thinking which perpetuate anxiety
What is the mnemonic to remember common features of GAD?
WATCHERS
Worry - excessive, uncontrollable Autonomic hyperactivity - sweating, pupil size, HR increase Tension in muscles, tremor Concentration difficulty Headache, hyperventilation Energy loss Restlessness Startled easily, sleep disturbance
What is the ICD-10 criteria for GAD?
Period of at least 6 months, with prominent tension, worry and feeling of apprehension.
At least four of the following symptoms, with at least one of autonomic arousal: palpitations, sweating, shaking, tremor, dry mouth
What can be established in a history of GAD?
Normal day in life to identify anxiety
Ever feel worried about current state of affairs
Worry excessively about minor things, anxious or on edge
Problems with memory or concentration
Ever like awake worrying or intermittently wake from sleep
Ask about somatic symptoms e.g. sensation of heart beating fast, pounding in chest
What can be seen in a MSE in GAD?
Appearance - face worried, restless, sweaty hands, lip biting, pallor, tense posture
Speech - trembling, slow rate
Mood - anxious
Thought - repetitive worrying thoughts, may concern personal health, safety of others, excessive worry about every day events e.g. relationships, finances
Perception - no hallucinations
Cognition - may complain of poor memory, reduced attention
Insight - may or may not have it
What are the investigations for GAD?
Bloods: FBC, TFTs, glucose
ECG may show sinus tachycardia
Questionnaires - GAD-2, GAD-7, Beck’s anxiety inventory, hospital anxiety and depression scale
What are the differentials of GAD?
Other neurotic disorders Depression Schizophrenia Personality disorder Excessive caffeine or alcohol withdrawal from drugs Organic - anaemia, hyperthyroid, phaeochromocytoma, hypoglycaemia
What is the management of GAD?
BIOLOGICAL:
SSRI e.g. sertraline, or SNRI if does not help e.g. duloxetine
Should be continued for 1 year
PSYCHOLOGICAL:
Psychoeducational groups are low intensity
High intensity - CBT, applied relaxation
SOCIAL:
Self help, write down worries, support groups, exercise
Stepped care model:
- identify, assess, active monitoring, psychoeducation
- low intensity psychological interventions e.g. self help, group based therapy
- high intensity psychological interventions - CBT, applied relaxation, drug treatment
- High specialist input e.g. multi-agency teams, crisis
What is a phobia?
An intense irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable
What is agoraphobia?
Fear of the marketplace - fear of public spaces or fear of entering a public space in which immediate escape would be difficult in the event of a panic attack
What are some examples of specific phobias?
Arachno- spiders, cyno- dogs, omitho- birds
Astra- thunder, aqua- water
Haemo- blood, needle- injections etc, traumato- physical injury or illness
Claustro- closed spaces, acro- heights, nycto- dark, nosocome- hospitals
What are risk factors for phobia?
Aversive experiences Stress and negative life events Other anxiety disorders Mood disorders Substance misuse disorders Family history
What are clinical features of phobias?
Tachycardia autonomic response
Vasovagal response producing bradycardia e.g. hemophobia
Anticipatory anxiety, inability to relax, urge to avoid feared situation, extreme fear of dying
What is the ICD-10 criteria of agoraphobia?
Marked and consistently manifest fear in, or avoidance of at least; crowds, public spaces, travelling alone, away from home
Symptoms of anxiety in feared situation
Significant emotional distress
Symptoms restricted to feared situation
What is the ICD-10 criteria of social phobia?
Marked fear or marked avoidance of being focus of attention
At least two symptoms of anxiety in feared situation plus - blushing, fear of vomiting, urgency or fear of micturition/defecation
Significant emotional distress due to avoidance or anxiety
Recognised as excessive or unreasonable
Symptoms restricted to or predominate in feared situation
What is the ICD-10 criteria of a specific phobia?
Marked fear or avoidance of a specific object or situation that is not agoraphobia or social phobia.
Symptoms of anxiety in the feared situation
Significant emotional distress
Recognised as excessive or unreasonable
Symptoms restricted to feared situation
How can phobic anxiety be separated from GAD?
Anxiety occurs in specific situations
There is anticipatory ancxiety when there is prospect of encountering the feared situation
Attempted avoidance of circumstances that precipitate anxiety
What can be seen in phobic anxiety on MSE?
Appearance - restless, want to escape, pale, sweaty, may lose consciousness
Speech - trembling, speechless
Mood - anxious
Thought - unpleasant feelings towards threat, fear of situation, desire to escape, fear of dying
Insight - poor when feared stimulus present, good when separated from stimulus
MSE will largely be normal unless exposed to the stimulus for phobia
What are the investigations for phobic anxiety disorders?
Diagnosis usually straightforward, can use questionnaires e.g. Social Phobia Inventory and Liebowitz Social Anxiety Scale
What are the differentials for phobic anxiety disorder?
Panic disorder, PTSD, anxious personality disorder, somatoform disorders, adjustment disorder, depression, schizophrenia
What are the general points of management for a phobic disorder?
Try to establish good rapport
Advise avoidance of anxiety inducing substances e.g. caffeine
Screen for significant co-morbidities e.g. substance misuse, personality disorders
Refer to specialist if risk of self-harm, suicide, self-neglect, or significant comorbidity
What is the management of agoraphobia?
CBT psychological intervention of choice
Graduated exposure techniques
SSRIs
What is the management of social phobia?
CBT individual or group
Graduated exposure
SSRIs sertraline, SNRIs venlafaxine, if no response MAOI moclobemide
Psychodynamic psychotherapy for those who decline CBT or medication
What is the treatment for a specific phobia?
Exposure either using self-help methods or more formally through CBT
Benzodiazepines as anxiolytics in short term due to risk of dependence, e.g. if need urgent CT and claustrophobic.
What questions would you ask in an anxiety history?
Rate of onset? Duration? Severity? Spontaneous? or Stimulus? Other psychotic conditions?
What is panic disorder?
Characterised by recurrent episodic severe panic attacks
Unpredictable, not restricted to any particular situation
What is the aetiology of panic disorder?
Biological - genetics, most heritable anxiety disorders, sympathetic nervous system stimulated
Cognitive - misinterpretation of somatic symptoms e.g. fear palpitations will lead to heart attack
Environmental - presence of life stresses can lead to panic disorder
What are the risk factors for panic disorder?
3x more common in women
Usual age in late adolesence
Family history
Major life events
Age 20-30
Recent trauma
Other mental disorders
White ethnicity, asthma, smoking
Medication e.g. benzodiazepine withdrawal
What is the ICD-10 criteria of panic disorder?
Recurrent panic attacks
Not consistently associated with a specific situation or object
Often occur spontaneously, not associated with exertion, exposure to dangerous situation.
Discrete episode of intense fear or discomfort, starts abruptly, usually peaks within 10 minutes and rarely persists beyond an hour. At least one symptoms of autonomic arousal - palpitations, sweating, shaking, tremor, dry mouth