Psychiatry - Neurotic disorders

Question 1

What are neurotic disorders?

Answer 1

Syndromes of emotional, cognitive, behavioural and somatic symptoms not secondary to another disorder (i.e. psychosis, organic brain disease or personality disorder)

Question 2

Symptoms of neurotic disorders

Answer 2

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

Question 3

How are neurotic disorders classified?

Answer 3

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

Question 4

Undifferentiated neurosis or minor emotional disorder

Answer 4

Mild cases of neuroses that cannot be placed into any of the classification systems (i.e. neuroses, stress related or somatoform)

Question 5

Mixed anxiety-depression

Answer 5

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

Question 6

How common is neurosis?

Answer 6

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

Question 7

Prognosis of neurosis

Answer 7

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

Question 8

What is the aetiology of neuroses?

Answer 8

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

Question 9

What are the 3 main types of anxiety disorder?

Answer 9

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

Question 10

What is phobic anxiety?

Answer 10

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)

Question 11

Why are avoidance behaviours counter productive in phobic anxiety?

Answer 11

Avoidance behaviour provides immediate relief from anxiety but it ultimately reinforces the fear

Overcoming avoidance is a key part of psychological treatment for phobias

Question 12

Differential diagnoses for phobic anxiety

Answer 12

Other anxiety disorders (i.e. panic, or generalised)
Secondary to delusions
Hypochondriasis = phobia of having a serious disease is classified separately

Question 13

Treatment of phobic anxiety

Answer 13

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)

Question 14

Agoraphobia

Answer 14

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)

Question 15

Clinical features of agoraphobia

Answer 15

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

Question 16

What is social phobia?

Answer 16

= 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

Question 17

How is social phobia treated?

Answer 17

i) CBT
ii) Antidepressants - especially SSRIs

NB - alcohol abuse may develop as a result of self medication

Question 18

What is the difference between panic attacks and panic disorder?

Answer 18

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

Question 19

Differential diagnosis for panic disorder

Answer 19

• Panic attacks occurring as part of phobia or other neuroses and depressive disorder
• Medical conditions causing paroxysmal anxiety

Question 20

How are panic disorders treated?

Answer 20

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

Question 21

What is generalised anxiety disorder (GAD)?

Answer 21

= 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)

Question 22

Are both obsessions and compulsions required for a diagnosis of OCD?

Answer 22

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

Question 23

Differential diagnosis for OCD

Answer 23

• 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

Question 24

What is the treatment for OCD?

Answer 24

• 5-HT predominant antidepressants (e.g. SSRIs, clomipramine) are effective, but higher dose than that used in depression is usually required
• Behavioural therapy

Question 25

What are dissociative and conversion disorders?

Answer 25

Dissociative disorders and conversion disorders are the same = loss of function (either psychological or physical) that is not explained by organic disease

Question 26

Where does the term dissociative and conversion come from?

Answer 26

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)

Question 27

Presentations of dissociative disorder

Answer 27

• 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)

Question 28

Differential diagnosis of dissociative disorders

Answer 28

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

Question 29

How are dissociative disorders diagnosed?

Answer 29

ICD-10 requires plausible “psychogenic” explanation - e.g. severe internal conflict or traumatic life event

Question 30

What is “neurasthenia”?

Answer 30

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

Question 31

What is the differential diagnosis for neurasthenia?

Answer 31

• Fatigue associated with medical conditions

- Fatigue associated with anxiety or depressive disorders

Question 32

Treatment for neurasthenia

Answer 32

• 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)

Question 33

What is the aetiology of CFS?

Answer 33

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

Question 34

ME

Answer 34

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

Question 35

What is depersonalisation-derealisation syndrome?

Answer 35

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)

Question 36

What are stress related disorders?

Answer 36

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

Question 37

Define an acute stress reaction

Answer 37

= Transient, but severe emotion reactions immediately following an exceptional stressor (e.g. rape)

Question 38

Symptoms of acute stress reaction

Answer 38

Emotion: “Dazed”
Cognition: Amnesia or denial
Behaviour: Over activity or withdrawn
Somatic symptoms: Many autonomic

Association: Acute stressor

Question 39

Differential diagnoses to consider in acute stress reaction

Answer 39

• Initial stages of other neuroses
• Acute psychosis (behaviour can be very odd)
• Delirium

Question 40

Is “debriefing” useful in acute stress reactions?

Answer 40

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

Question 41

What are adjustment disorders?

Answer 41

= 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

Question 42

Are grief reactions the same as adjustment disorders/ reactions?

Answer 42

Yes - grief reactions and psychological reactions to medical conditions are types of adjustment disorder

Question 43

Treatment for adjustment disorders

Answer 43

• 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

Question 44

What is PTSD?

Answer 44

= 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

Question 45

What is a key cognitive feature of PTSD?

Answer 45

Involuntary re-experiencing of the traumatic even in nocturnal dreams or as intrusive “flashbacks” often triggered by reminders of the trauma

Question 46

What is the treatment for PTSD?

Answer 46

• 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

Question 47

Prognosis in PTSD

Answer 47

Generally good - gradual resolution in most cases

Minority of cases become chronic - alcohol misuse and depression are common

Question 48

Somatoform disorders

Answer 48

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

Question 49

What are the 2 main groups of somatoform disorders?

Answer 49

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)

Question 50

Aetiology of somatoform disorders

Answer 50

• Childhood deprivation and abuse are risk factors

- Predisposition to health anxiety and serious (and perhaps mismanaged) illness in a relative are also common

Question 51

Requirements to make a diagnosis of somatoform disorder

Answer 51

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

Question 52

What are the main features of hypochondriasis and dysmorphophobia?

Answer 52

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

Question 53

Hypochondriasis

Answer 53

= 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

Question 54

Treatment for hypochondriasis

Answer 54

• 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

Question 55

Dysmorphophobia

Answer 55

= 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

Question 56

What are somatic symptom disorders?

Answer 56

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

Question 57

Somatization disorder (Briquet’s syndrome)

Answer 57

= 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

Question 58

Undifferentiated somatoform disorder

Answer 58

This is the diagnosis used instead of somatization disorder when the patient has few symptoms

Question 59

What is persistent somatoform pain disorder?

Answer 59

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

Question 60

Somatoform autonomic dysfunction

Answer 60

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)