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
What can be established in the history of panic disorder?
Generally anxious or periods where you are anxiety free
Can you predict when these attacks will come on
Ever been so frightened your heart is pounding or you might die
Worried about your health or any other specific things
What are differentials for panic disorder?
Other anxiety disorders
Dissociative disorder
Bipolar, depression, adjustment disorder
Organic causes e.g. phaeochromocytoma, alcohol, substance withdrawal
What is the NICE recommendation of stepped care approach to panic disorder?
1: Recognition and diagnosis, identify common co-morbidities e.g. depression and substance misuse
2: Treatment in primary care, recommendations for psychological therapies, medications, self-help
3: Review and consideration of alternative treatments if therapy has failed
4: Review and referral to specialist mental health services, if two interventions have been offered and no improvement
5: Care under specialist mental health services, reassessment in secondary care
What is the medication of choice for panic disorder?
SSRIs first line
If not suitable or no improvement after 12 weeks - TCA e.g. imipramine, or clomipramine
Benzos should not be prescribed
What is post-traumatic stress disorder?
An intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event.
What is abnormal bereavement?
Delayed onset, more intense and prolonged >6 months, impact overwhelms individual’s coping capacity.
What is 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.
What are examples of traumatic events which may lead to PTSD?
Severe assault Major natural disaster Serious road traffic accident Observer/survivor of civilian disaster e.g. terrorism Involvement in war Freak occurrences e.g. near drowning Physical torture Prisoner of war or hostage situation Hearing about unexpected injury or violent death of a family member or friend
What are risk factors for PTSD?
Exposure to major traumatic event
Pre-trauma - previous trauma, mental illness, females, low SE status, childhood abuse
Peri-trauma - the severity of it, perceived threat to life, adverse emotional reaction during or immediately after the event
Post-trauma - concurrent life stressors, absence of social support
What are the clinical features of PTSD?
Must occur within 6 months of the event, can be divided into:
Reliving the situation; persistent, intrusive, involuntary flashbacks, nightmares
Avoidance - avoiding reminders of the trauma, excessive rumination
Hyperarousal - irritability or outbursts, difficulty concentrating, sleep problems
Emotional numbing - negative thoughts about onself, difficulty experiencing emotions, feeling of detachment, giving up prev enjoyed activities.
What is the ICD-10 criteria for the diagnosis of PTSD?
Exposure to stressful event
Persistent remembering of event
Actual or preferred avoidance of similar situations
Either inability to recall some aspects of the period of exposure, or persistent symptoms of increased psychological sensitivity and arousal
Occurs within 6 months of the stressful event or the end of a period of stress
How long should bereavement last for?
6 months, beyond 6 months abnormal bereavement or adjustment disorder should be considered
What is noted in MSE for PTSD?
Appearance and behaviour: hypervigilance, on edge, features of anxiety, poor eye contact
Speech: slow rate, trembling, non-spontaneous
Mood: anxious
Thought: pessimistic, reliving or remembering the event
Perception: no hallucinations, may have illusions
Cognition: poor attention and concentration
Insight: good
What are the Kubler-Ross stages of grief?
DABDA
Denial Anger Bargaining - negotiating a compromise in order to reduce grief Depression Acceptance
What are the differentials for PTSD?
Adjustment disorder, acute stress reaction, bereavement, dissociative disorder, mood or anxiety disorder, personality disorder.
Organic - head injury as a result of traumatic event, alcohol or substance misuse
What is acute stress reaction?
Exposure to an exceptional physical or mental stressor e.g. physical assault, RTA followed by immediate onset of symptoms within 1 hour.
Symptoms include anxiety symptoms, narrowing of attention, apparent disorientation, anger or verbal aggression, despair or hopelessness, uncontrollable or excessive grief.
Symptoms must begin to diminish within 8 hours for transient stressors or 48 hours for continued stressors.
What is adjustment disorder?
Identifiable non catastrophic psychosocial stressor e.g. redudancy or divorce, within one month of onset of symptoms.
Symptoms can be variable, usually an affective or neurotic disorder but not severe.
Symptoms present for less than 6 months.
What is the management of PTSD where symptoms are present within 3 months of trauma?
Watchful waiting if mild lasting <4 weeks.
Military personnel have access to treatment from armed forces.
Trauma focused CBT given at least once a week for 8-12 sessions.
Short-term drug treatment may be considered in acute phase, management of sleep disturbance e.g. zopiclone.
Risk assessment important to asses risk for neglect or suicide.
What is the management of PTSD where symptoms have been present >3 months after a trauma?
All sufferers offered a course of trauma-focused psychological intervention.
Psych intervention - CBT or eye movement desensitisation and reprocessing (EMDR)
Drug treatment considered when little benefit from psychological therapy, patient preference or co-morbid depression or severe hyperarousal.
Paroxetine, mirtazapine, amitriptyline and phenelzine licensed for treatment.
What is OCD?
Characterised by recurrent obsessional thoughts or compulsive acts, or commonly both.
What are obsessions in OCD?
Unwanted intrusive thoughts, images or urges that repeatedly enter the individual’s mind. They are distressing, individual attempts to resist them and recognises them as absurd.
Product of own mind.
What are compulsions in OCD?
Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing.
They are overt - observable by others or covert - mental acts no observable.
What are some of the theories of the aetiology of OCD?
Biological - decreased serotonin, abnormalities and frontal cortex, childhood Group A strep may have role - PANDAS.
Psychoanalytic - filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering the consciousness.
Behavioural - compulsive behaviour is learned, maintained through operant conditioning
What is the ICD-10 criteria for the diagnosis of OCD?
Either obsessions or compulsions, or both present on most days for a period of at least 2 weeks.
Obsessions or compulsions share a number of features, all must be present.
Obsessions or compulsions cause distress or interfere with subject’s social or individual functioning.
What is the epidemiology of OCD?
Most common in early adulthood
Equally common in both genders
More common in the relatives of OCD parents.
Developmental factors e.g. neglect, abuse, bullying may have a role.
What are the clinical features of OCD?
Obsessions e.g. contamination, fear of harm - doors not locked, excessive concern with order or symmetry, others; sex, violence, blasphemy, doubt
Compulsions:
Overt - checking taps, doors, cleaning, washing, arranging objects, hoarding
Covert - repeating acts e.g. counting, mental compulsions e.g. special words repeated in a set manner
Obsessions and compulsions all follow same features: FORD Car
Failure to resist
Originate from patient’s mind, acknowledged this is the case
Repetitive and Distressing
Carrying out obsessive thought or act is not pleasurable but reduces anxiety levels.
What is the OCD cycle?
- Obsession
- Anxiety
- Compulsion
- Relief
Obsessions create anxiety which continues to build until a compulsion is carried out in order to provide relief.
What sort of questions can be asked in the history for OCD?
Do you have any distressing thoughts that enter your mind
Is there any unwanted thought that keeps bothering you that you would like to get rid of but cannot
Do you worry about contamination even after washing, do you repeatedly check things you have already done, do you find yourself having the touch, count and arrange things many times
Do you clean or wash a lot, do you check things a lot, are you concerned about putting things in a specific order
Do your daily activities take a long time to finish
What can be observed in a MSE in OCD?
Patient may be on edge and easily startled
May look visibly worried or lost in thought
May be constantly checking doors or fidgety with hands if e.g. cannot wash them
May demonstrate increasing levels of anxiety if unable to succumb to compulsion
Thoughts are unwanted, intrusive, and uncomfortable for the patient
Obsessions can be distracting and lead to poor concentration
Insight is usually very good, they recognise the thoughts are a product of their own mind
What is it important to explore alongside the main obsessions and compulsions in OCD?
Assess impact of obsessions and compulsions on the person’s life
Assess risk
Patients commonly have co-existing depression, anxiety disorders, substance misuse, eating disorders and body dysmorphic disorder.
What are the differentials for OCD?
Obsessions and compulsions - EDs, anankastic personality disorder, body dysmorphic disorder e.g. mirror gazing time consuming
Primarily obsessions - anxiety disorders, depressive disorder, hypochondrial disorder, schizophrenia
Primarily compulsions - Tourette’s, Kleptomania (inability to refrain from stealing items)
Organic - dementia, epilepsy, head injury
What is the management of OCD?
CBT including ERP - exposure and response prevention; patients repeatedly exposed to situation which causes them anxiety e.g. exposure to dirt, and prevented from performing the repetitive actions
Pharmacological therapy - SSRIs; fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram.
Psychoeducation, distracting techniques, self-help books.
Any potential suicide risk should be identified and managed, co-morbid depression identified and treated.
What is the management of mild OCD?
Low intensity psychological intervention - <10 hours of therapist input per patient
What is the management of moderate OCD?
SSRI or high intensity psychological intervention
What is the management of severe OCD?
Combined SSRI and CBT - with ERP
What are somatoform disorders?
A group of disorders whose symptoms are suggestive or take the form of a physical disorder but in the absence of a physiological illness.
Leads to the presumption they are caused by psychological factors.
Patients repeatedly seek medical attention even which it has consistently failed to benefit them.
What are dissociative/conversion disorders?
Characterised by symptoms which cannot be explained by a medical disorder, and there are convincing associations in time between symptoms and stressful events.
Unpleasant stressful events or problems are ‘converted’ into the symptoms/
What is the cause of somatoform disorders?
Multifactorial.
Patients adopt the sick role, providing them relief from stressful or unachievable interpersonal expectations.
Biological - possible implication of neuroendocrine genes.
Psychological - high proportion of those with PTSD suffer from somatoform disorders. Association between somatisation and physical or sexual abuse.
Social - adopting the sick role in order to gain relief from stress.
What is required for a dissociative disorder to occur?
Dissociation - the process of separating off certain memories from normal consciousness; psychological defence mechanism used to cope with emotional conflict.
Conversion - distressing events are transformed into physical symptoms leading to primary gain; stress relief, and secondary gain; financial rewards e.g. benefits.
What are the risk factors for somatoform and dissociative disorders?
CRAMPS
Childhood abuse Reinforcement of illness behaviours Anxiety disorders Mood disorders Personality disorders Social stressors
What are the ICD-10 categories of dissociative conversion disorder?
Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and possession disorders
Dissociative motor disorders
Dissociative convulsions
Dissociative anaesthesia and sensory loss
What is dissociative amnesia?
partial or complete for recent events or problems that were traumatic. Too extensive and persistent to be explained by ordinary forgetfulness.
What is dissociative fugue?
An unexpected physical journey away from usual surroundings, followed by amnesia for the journey.
Self care usually maintained.
What is dissociative stupor?
Profound reduction in or absence of voluntary movements, speech and normal responses to stimuli.
Normal muscle tone.
What is trance and possesive disorder?
Trance - temporary alteration in state of consciousness
Possession - absolute conviction by the patient that they have been taken over by a spirit, power or person.
What is dissociative motor disorders?
Loss of the ability to perform movements that are under voluntary control, including speech or ataxia.
What are dissociative convulsions?
Sudden, unexpected spasmodic movements that resemble epilepsy without loss of consciousness.
What is dissociative anaesthesia and sensory loss?
Partial or complete loss of cutaneous sensation, vision, hearing or smell.
What are the ICD-10 categories of somatoform disorders?
PUSHy SOMATOFORM
Persistent somatoform pain disorder
Undifferentiated somatoform disorder
Somatisation disorder
Hypochondrial disorder including body dysmorphic disorder
Somatoform autonomic dysfunction
What is the ICD-10 criteria of somatisation disorder?
All 4 to be present:
At least 2 years duration, of physical symptoms that cannot be explained by detectable physical disorder
Preoccupation with symptoms causes physical distress, which leads to them seeking repeated medical consultations and requesting investigations.
Continuous refusal by patients to accept reassurance from doctors that there is no physical cause for their symptoms.
A total of six or more symptoms.
What are common symptoms in somatisation disorder?
GI: abdo pain, N+V, bloating, regurgitation, loose bowel motions, swallowing difficulty
CV: chest pain, breathlessness at rest, palpitations
GUM: dysuria, freq, incontinence, vaginal discharge, menstrual problems
Others: discolouration or itching of skin, arthralgia, paraesthesia in limbs, headaches, visual disturbances
What is hypochondrial disorder?
Patient misinterprets normal bodily sensations which leads them to the non-delusional preoccupation that they have a serious physical disease.
Refuse to accept reassurances from doctors.
Dysmorphopbia - body dysmorphic disorder is a variant of this - there is an excessive preoccupation with barely noticeable or imagined defects in appearance.
What is somatoform autonomic dysfunction?
Symptoms related to ANS.
Attributed by patients to a physical disorder of one or more of the systems.
Multiple autonomic symptoms must be present e.g. palpitations, tremor, sweating, dry mouth, flushing, hyperventilation.
Symptoms may be objective e.g. sweating, tremor or subjective; pain and paraesthesia.
What is persistent somatoform pain disorder?
Persistent of at least 6 months and severe pain that cannot be fully explained by a physical disorder.
Pain usually occurs as a result of psychosocial stressors and emotional difficulties.
Differs from somatisation disorders in that the pain is the primary feature, multiple symptoms from different systems are not present.
What questions can be enquired in the history for somatisation disorder?
Do you ever worry about your health
Feel you have multiple medical problems
Worried about having a potentially serious medical condition
Do you get frustrated when doctors tell you you are fit and well
Have there been any stressful events in your life that may have triggered symptoms
What are the investigations for somatoform disorder?
Diagnosis of exclusion
Some features may point in direction of this - vague symptoms exceed objective findings, chronic course, presence of mental health disorder, history of extensive diagnostic testing and rejecting of previous physicians.
Thorough examination and ix to rule out organic cause.
Bloods: FBC (anaemia, infection) U&Es, LFTs, CRP, TFTs
GI symptoms - AXR, stool culture, OGD, colonscopy, diagnostic laparoscopy
CV symptoms: ECG, 24hr tape, ECHO, angiogram
GU: urine dipstick, MSU, cystoscopy
What are the differentials for somatoform disorders?
Somatisation disorder, hypochondrial disorder, somatoform autonomic dysfunction, undifferentiated somatoform disorder
Dissociative conversion disorder, factitious disorder, malingering
What is malingering and factitious disorder?
Munchausen’s
Physical or psychological symptoms are intentionally produced/faked
The difference between the two is the motive behind mimicking the symptoms
Malingering patients seek advantageous consequences of being diagnosed with medical condition, factitious individual wishes to adopt the sick role to receive care for primary gain.
What is the management of somatoform and dissociative disorders?
Biological - antidepressants primarily SSRIs for any underlying mood disorder. Physical exercise enhances self-esteem.
Psychological - CBT, development of coping strategies
Social - encourage pleasurable private time, stress relieving activities, involve family where possible
What is it important to consider in a consultation for a patient with medically unexplained symptoms?
Focus on symptoms, effect on patient, share uncertainty, reach shared understanding.
Don’t focus exclusively on diagnosis, dismiss symptoms, assume what patient wants, ignore psychological cues.
What is adjustment disorder?
Emotional signs - sadness, hopelessness, crying, nervousness, anxiety, desperation.
RFs include exposed to repeated trauma, age, hx of mental disorder, lower social support.
Symptoms appear soon after life event; 1 month.
Symptoms last longer than acute stress reaction.
Treatment with problem solving psychotherapy, or crisis intervention psychotherapy.
