Neurotic, somatoform and stress-related disorders

Question 1

What key features are associated with PTSD that aid a diagnosis?

Answer 1

Symptoms occurring within 6 months of event
4 categories (HEAR): Hyperarousal, Emotional numbing, Avoidance, Reliving

Question 2

What is the ICD-10 criteria for PTSD?

Answer 2

Exposure to stressful event / situation and development of symptoms (A-C) within 6 months of event / period of stress
A. Persistent remembering of stressful event
B. Avoidance of similar situations resembling or associated with stressor
C. Either 1 or 2: (1) inability to recall important aspects of period of exposure; (2) persistent symptoms of increased psychological sensitivity and arousal

Question 3

What are the BSP management options for PTSD?

Answer 3

Pscyho: (group / individual) trauma-focussed CBT, eye movement desensitisation and reprocessing (EMDR)
Bio: zopiclone for insomnia, venlafaxine / sertraline (or other SSRI), risperidone (antipsycotic)
Social: disaster planning, risk assessment, AA and alcohol assessment, assessment of home / work life & employer reasonable adjustments

Question 4

What is the definition of acute stress disorder?

Answer 4

Acute stress reaction that occurs in the first 4 weeks after exposure to traumatic event
Sx inc: intrusive thoughts, dissociation, negative mood, avoidance, arousal

Question 5

What is the management of acute stress disorder?

Answer 5

Trauma focused CBT
Benzodiazepines (for acute Sx e.g. agitation / sleep disturbance)

Question 6

What are the ICD-10 listed Phobic anxiety disorders?

Answer 6

Agoraphobia (+/- panic disorder)
Social phobia
Specific phobia

Question 7

What are the ICD-10 listed anxiety disorders (non-panic disorders)

Answer 7

Panic disorder
Generalised anxiety disorder
Mixed anxiety and depressive disorder

Question 8

What are the ICD-10 listed Obsessive-compulsive disorders?

Answer 8

Predominantly obsessional thoughts
Predominantly compulsive thoughts
Mixed

Question 9

What are the ICD-10 listed reactions to severe stress and adjustment disorders?

Answer 9

Acute stress reaction
Post-traumatic stress disorder
Adjustment disorder

Question 10

What is the ICD-10 classification of neurotic and stress-related disorders?

Answer 10

Phobic anxiety disorders
Other anxiety disorders
Obsessive-compulsive disorder
Reaction to severe stress & Adjustment disorders

Question 11

What are the clinical features of neuroses?

Answer 11

Psychological: impending doom, worrying thoughts, exaggerated startle response, poor concentration, depersonalisation
CV: palpitations, chest pain
Respiratory: cough, hyperventilation
GI: abdo pain, loose stools, N/V, dysphagia
GU: ^ micturition, failure of erection
Neuromuscular: tremor, myalgia, headache

Question 12

What is the ICD-10 classification for GAD?

Answer 12

at least 6 months: prominent tension, worry, feelings of apprehension
At least 1 symptom of autonomic arousal + at least 4 of: chest / abdomen, brain / mind, general symptoms, tension, non-specific symptoms

Question 13

What is the management for GAD?

Answer 13

SSRI (sertraline) / SNRI (venlafaxine)
Psychoeducational groups (low intensity) / CBT & applied relaxation (high intensity)
Self-help / support groups / Exercise

Question 14

What investigations should be completed for someone presenting with anxiety symptoms and why?

Answer 14

FBC (infection / anaemia)
TFTs (hyperthyroidism)
Glucose (hypoglycaemia)
ECG (tachycardia)

Question 15

What is the management for agoraphobia?

Answer 15

CBT
Graduated exposure
SSRIs

Question 16

What is the management for social phobia?

Answer 16

CBT
Graduated exposure
SSRI, SNRI, MAOI
Psychodynamic psychotherapy

Question 17

What is the management for specific phobias?

Answer 17

Exposure > formally through CBT
Benzodiazepines (ST)

Question 18

What is the ICD-10 criteria for the diagnosis of panic disorder?

Answer 18

Recurrent panic attacks, not consistently associated with specific situation / object
Occur spontaneously, not associated with marked exertion / exposure to dangerous situations
Characterised by ALL of the following:
1. discrete episode of intense fear / discomfort
2. starts abruptly
3. reaches screscendo within minutes > lasts some minutes
4. autonomic arousal
5. other anxiety symptoms

Question 19

What is the management for panic disorder?

Answer 19

SSRIs > TCA
CBT
Self-help (bibliotherapy), support groups, encouraging exercise
Stepped care approach

Question 20

What is the management for PTSD?

Answer 20

<3 months:
- watchful waiting
- trauma focused CBT
- ST drug treatment = zopiclone (insomnia)
- Risk assessment (neglect / suicide)
>3 months:
- trauma focused: CBT / eye movement desensitisation and reprocessing (EMDR)
- SSRI / venlafaxine

Question 21

What is the management for OCD?

Answer 21

CBT (Exposure and Response Prevention)
SSRIs (Fluoxetine), clomipramine
Psychoeducation, distracting techniques, self-help books
Co-morbid depression
Assess degree of function impairment

Question 22

What is a somatoform disorder?

Answer 22

Group of disorders whose symptoms are suggestive of / take a form of a physical disorder but in the absence of a physiological illness > presumption that the symptoms are caused by a psychological illness
Repeatedly seek medical attention (even when it has consistently failed them)

Question 23

What are the features of hypochondriacal disorder?

Answer 23

Misinterpreted normal bodily sensations> non-delusional preoccupation of having a serious disease
Dysmorphophobia is a variant

Question 24

What are the features of somatoform autonomic dysfunction?

Answer 24

Symptoms related to autonomic nervous system (palpitations, tremor, sweating, dry mouth)

Question 25

What are the features of persistent somatoform pain disorder?

Answer 25

Persistent (>6 months) and severe pain that cannot be fully explained by physical disorder
Usually occurs as result of psychosocial stressors
Pain not from multiple systems and pain is the primary features (not other symptoms)

Question 26

Differentiate between factitious disorder, malingering, somatoform disorder, and dissociative disorder?

Answer 26

Factitious: I want to be looked after
Malingering: If I go to hospital, I will receive compensation
Somatoform disorder: I think I have a serious illness
Dissociative disorder: Ever since I was fired, I have been unwell