Psychiatry - Neurotic disorders Flashcards
What are neurotic disorders?
Syndromes of emotional, cognitive, behavioural and somatic symptoms not secondary to another disorder (i.e. psychosis, organic brain disease or personality disorder)
Symptoms of neurotic disorders
Symptoms of neuroses are emotional, cognitive, behavioural and somatic:
- Anxiety is the primary emotion in all these disorders
- Cognitions are worries, fears and concerns that are inappropriate or excessive but (by definition) not delusions
- Behaviours include avoidance and strategies to reduce anxiety such as re-checking
- Somatic (“physical”) symptoms, not explained by medial disease but associated with tension, autonomic arousal and hyperventilation are common
Neurotic disorders can present with any of these symptoms or combinations of them
How are neurotic disorders classified?
1) Neurotic disorders (neuroses)
- Anxiety: panic, phobic, GAD
- OCD
- Dissociative disorders
- CFS
- Depersonalisation - derealisation syndrome
2) Stress related disorders
- Acute stress reaction
- Adjustment disorder
- PTSD
3) Somatoform disorders
- Hyperchondriasis
- Dysmorphophobia
- Somatisation disorder
NB - The term “neurosis” has been used to describe patients with predominantly somatic symptoms and also for some symptoms caused by stress. These types of neurosis have each been given their own category in the current classification
Undifferentiated neurosis or minor emotional disorder
Mild cases of neuroses that cannot be placed into any of the classification systems (i.e. neuroses, stress related or somatoform)
Mixed anxiety-depression
Depressive symptoms are very common in patients with neurosis, and neurotic symptoms are common in depression. These disorders can often co-exist together - mixed anxiety-depressive disorder
How common is neurosis?
Affects approximately 15% of the population
Most are significantly more common in women - except OCD and panic disorder
Onset is between early adulthood and middle age (children can get neuroses though)
Prevalence increases with:
- Low household income
- Comorbidity with depression
Prognosis of neurosis
Most cases seen in primary care are acute and transient
Prognosis is improved by:
- No co-morbid personality disorder
- Patient is strongly motivated to get better
- Short duration of illness
What is the aetiology of neuroses?
Multifactorial - biopsychosocial factors
1) Biological:
- Inherited to some degree
- Neurotransmitter alterations - 5-HT, NAd
- Neuroimaging shows altered brain function and structure (i.e. hippocampal atrophy in PTSD)
2) Psychological:
- Cognitive factors and behavioural conditioning important (especially in phobias and panic disorders)
3) Social:
- Life stressors
- Unhelpful responses by medical system
- Lack of social support
What are the 3 main types of anxiety disorder?
Anxiety disorders are characterised by the emotion of anxiety + anxious thoughts, avoidance behaviour and somatic symptoms of sympathetic arousal
Anxiety disorders are divided into 3 main subtypes:
i) Phobic
ii) Paroxysmal (panic)
iii) Generalised
What is phobic anxiety?
Phobic anxiety is situational - restricted to the experience or anticipation of a particular situation
This situation may be a specific concern (e.g. spiders, heights) or more general (e.g. agoraphobia)
Why are avoidance behaviours counter productive in phobic anxiety?
Avoidance behaviour provides immediate relief from anxiety but it ultimately reinforces the fear
Overcoming avoidance is a key part of psychological treatment for phobias
Differential diagnoses for phobic anxiety
Other anxiety disorders (i.e. panic, or generalised)
Secondary to delusions
Hypochondriasis = phobia of having a serious disease is classified separately
Treatment of phobic anxiety
Anxiolytics and antidepressants have a role
Psychotherapy involves graded exposure to the situation - in CBT a cognitive component is added to help the patient more accurately evaluate the dangerousness of the stimulus (e.g. flight statistics)
Agoraphobia
Specific type of phobic anxiety = fear of open, large or crowded spaces that are difficult to escape from
Panic attacks are common, and having a panic attack may itself become the feared situation (the appropriate diagnosis is then panic disorder with agoraphobia)
Clinical features of agoraphobia
Associated cognitions normally focus on fainting, dying or another catastrophe rather than fear of shops per se
Condition can be severe - avoidance can lead the person to become housebound
On average symptoms have been present for 2 years before the diagnosis is made - common in young women
What is social phobia?
= fear of other people associated with anticipation of negative evaluation of them
Important to distinguish from normal shyness and social withdrawal due to depression
Normally a history of low self esteem and a triggering incident when the person feels they may embarrass themselves
How is social phobia treated?
i) CBT
ii) Antidepressants - especially SSRIs
NB - alcohol abuse may develop as a result of self medication
What is the difference between panic attacks and panic disorder?
Panic attacks = episodes of severe paroxysmal anxiety
- associated with somatic symptoms and unpleasant feels of depersonalisation and derealisation
Panic disorder = second type of anxiety disorder, where attacks are recurrent over a period of at least 1 month
NB - somatic symptoms may be severe (sympathetic arousal) leading to misdiagnosis of epilepsy, angina etc
Differential diagnosis for panic disorder
- Panic attacks occurring as part of phobia or other neuroses and depressive disorder
- Medical conditions causing paroxysmal anxiety
How are panic disorders treated?
i) CBT is very successful for panic disorder - aimed at helping the patient see their symptoms as the result of anxiety and not as indicators of impending catastrophe
ii) Antidepressants also have a role - can cause exacerbate panic before helping
What is generalised anxiety disorder (GAD)?
= Persistent anxiety associated with chronic uncontrollable and excessive worry (somatic symptoms may be present - e.g. stomach aches)
Importantly, it may fluctuate but is not paroxysmal (as in panic disorder), situational (as with phobic anxiety), life-long (as with personality disorder), or clearly stress related (as with stress related disorder)
Are both obsessions and compulsions required for a diagnosis of OCD?
No - in OCD obsessions and compulsions are the most prominent and persistent symptoms but both are not required for a diagnosis
Obsessions are cognitions (thoughts)
Compulsions are behaviours
Differential diagnosis for OCD
- Depressive disorder (in which obsessional symptoms are common)
- Psychotic disorder (obsessions are usually regarded as unpleasant and untrue by the sufferer, unlike delusions where beliefs are seen as real)
- Obsessional (or anakastic) personality disorder
What is the treatment for OCD?
- 5-HT predominant antidepressants (e.g. SSRIs, clomipramine) are effective, but higher dose than that used in depression is usually required
- Behavioural therapy
What are dissociative and conversion disorders?
Dissociative disorders and conversion disorders are the same = loss of function (either psychological or physical) that is not explained by organic disease
Where does the term dissociative and conversion come from?
Dissociative = represents loss of normal association between different mental processes such as personal identity and memories, sensory and motor function etc
Conversion = used for loss of physical function, because it was argued that psychological conflicts got converted into physical symptoms thereby resolving the mental conflict (primary gain) and often providing practical benefits such as attention of others (secondary gain)
Presentations of dissociative disorder
- Loss of psychological functions such as memory (psychogenic amnesia)
- Wandering in a trance (fugue)
- Loss of motor function (paralysis, pseudozeizures)
- Loss of sensory function (glove and stocking anaesthesia)
Differential diagnosis of dissociative disorders
Must be distinguished from consciously motivated symptoms (dissociative disorders are though to originate in unconscious processes). These are divided into:
- Malingering = behaviour designed to achieve personal gain
- Factitious disorder = symptoms are produced deliberately to obtain medical care
How are dissociative disorders diagnosed?
ICD-10 requires plausible “psychogenic” explanation - e.g. severe internal conflict or traumatic life event
What is “neurasthenia”?
The term neurasthenia is rarely used in the UK or US but is still widely used in China and some other countries
There is substantial overlap with CFS although the two are classified separately
Physical symptoms predominate with no definitive medical disease identified - main features are persistent debilitating mental and physical fatigue, often accompanied by pain and other symptoms
What is the differential diagnosis for neurasthenia?
- Fatigue associated with medical conditions
- Fatigue associated with anxiety or depressive disorders
Treatment for neurasthenia
- Good evidence for CBT and graded increases in activity, less for antidepressants
- Prognosis if often poor with a tendency to chronicity (avoidance of physical activity and belief in a physical cause are associated with a worse outcome)
What is the aetiology of CFS?
1) Biological - disturbed 5-HT function and reduced cortisol; follows viral infection (EBV?)
2) Psychologically - depression; anxiety; excessive concern with symptoms leading to inactivity is common
3) Social - fear of stigmatising psychiatric diagnosis; widely available misinformation may shape patients illness beliefs
ME
ME = Myalgic encephalitis
Similar group of symptoms in CFS/ neurasthenia is also referred to as ME
ME is though to be better regarded as a neurological condition and distinct from CFS
What is depersonalisation-derealisation syndrome?
Depersonalisation and derealisation are symptoms that can occur in ALL neuroses
Occasionally they are the most prominent feature, in which case they are labeled as depersonalisation-derealisation syndrome (but this is rare)
DDx - depressive or anxiety disorder; psychosis; organic disease (esp complex partial seizures)
What are stress related disorders?
These are neuroses in which there is a clear relationship to a major psychological stressor
Whole range of neurotic symptoms may be present usually in a diffuse picture
There are 3 types of stress disorder:
1) Acute stress reaction
2) Adjustment disorder
3) PTSD
Define an acute stress reaction
= Transient, but severe emotion reactions immediately following an exceptional stressor (e.g. rape)
Symptoms of acute stress reaction
Emotion: “Dazed”
Cognition: Amnesia or denial
Behaviour: Over activity or withdrawn
Somatic symptoms: Many autonomic
Association: Acute stressor
Differential diagnoses to consider in acute stress reaction
- Initial stages of other neuroses
- Acute psychosis (behaviour can be very odd)
- Delirium
Is “debriefing” useful in acute stress reactions?
Debriefing = patient tells a therapist about the stressful event immediately after it has occurred is unhelpful and may even worsen the outcome
Rx:
- Remove stressor (if possible)
- Reassurance and support
- Short course (2wk) BDZ may be useful
What are adjustment disorders?
= Reactions to stress that are more prolonged than acute stress reactions
Symptoms typically begin within 1 month of the stress and do not last longer than 6 months
Are grief reactions the same as adjustment disorders/ reactions?
Yes - grief reactions and psychological reactions to medical conditions are types of adjustment disorder
Treatment for adjustment disorders
- Help patient to address the continuing stressor more effectively (e.g. problem solving therapy)
- Discourage unhelpful coping strategies (e.g. substance misuse)
- Treat depression or anxiety
What is PTSD?
= Delayed response to an exceptionally severe traumatic event (e.g. RTA, major disaster, severe assault)
Onset may be months or years after the original trauma
What is a key cognitive feature of PTSD?
Involuntary re-experiencing of the traumatic even in nocturnal dreams or as intrusive “flashbacks” often triggered by reminders of the trauma
What is the treatment for PTSD?
- Treat comorbid psychiatric disorder or substance misuse
- Encourage return to normal activities
- Antidepressant drugs can be modestly effective
- Evidence for trauma focused CBT
- EMDR = Eye movement desensitisation and reprocessing
Prognosis in PTSD
Generally good - gradual resolution in most cases
Minority of cases become chronic - alcohol misuse and depression are common
Somatoform disorders
Include medically unexplained symptoms (somatization) and fears about having a physical illness (hypochondriasis) and are closely related to the other neuroses
They are usually seen in non psychiatric settings
What are the 2 main groups of somatoform disorders?
1) Conditions in which the main feature is concern about having a disease (hypochondriasis) or deformity (dysmorphophobia)
2) Conditions in which the main feature is concern about somatic symptoms (physical symptoms - wide range of conditions)
Aetiology of somatoform disorders
- Childhood deprivation and abuse are risk factors
- Predisposition to health anxiety and serious (and perhaps mismanaged) illness in a relative are also common
Requirements to make a diagnosis of somatoform disorder
i) Symptoms unexplained or disproportionate to organic disease, severe enough to cause distress and present for 6 months
ii) Depressive and anxiety symptoms are insufficient to justify diagnosis of depression or anxiety
iii) Symptoms are not delusions (e.g. distinguish from a psychotic disorder with somatic hallucinations)
iv) Symptoms are not deliberately manufactured
What are the main features of hypochondriasis and dysmorphophobia?
Both of these are types of somatoform disorders that are grouped together because they feature a preoccupation with the possibility of having a physical disease or deformity
DDx:
1) Depressive disorder
2) Psychotic disorders
Hypochondriasis
= Patients are preoccupied with the idea that they have a serious medical condition when they do not
Patients repeatedly seek medical reassurance and investigation, but are not reassured by either
Treatment for hypochondriasis
- Antidepressants and CBT can be effective
- Help patients restrict their tendency to seek reassurance or check their bodies (these behaviours may perpetuate the condition)
- Prognosis is variable
Dysmorphophobia
= Also called body dysmorphic disorder, is characterised by a preoccupation with subjectively abnormal physical appearance that is not objectively present and often associated with avoidance of social interaction
What are somatic symptom disorders?
Second group of somatoform disorders where somatic (physical) symptoms such as fatigue and pain are not adequately explained by medical disease - they are very common
They are classified in psychiatry by the number of symptoms and their duration
Somatization disorder (Briquet’s syndrome)
= Patients (almost always women) present with multiple different medically unexplained symptoms that have occurred over many years
They have often had normal abdominal organs surgically removed (which actually increases the risk of iatrogenic harm)
Recurrent major depression and personality disorder are common associations
Undifferentiated somatoform disorder
This is the diagnosis used instead of somatization disorder when the patient has few symptoms
What is persistent somatoform pain disorder?
Type of somatic symptom disorders (somatization disorders and associated diagnoses) This diagnosis is used when the main symptom is pain that is inadequately explained by a medical disease
Antidepressants are useful; tricyclic antidepressants and SNRI’s are more effective than SSRI’s
Somatoform autonomic dysfunction
Rarely used diagnosis for cases where the symptoms are though to be clearly explained in terms of autonomic arousal and associated over breathing (e.g. breathlessness, chest pain, flushing etc)
