Neurotic Disorders

Mr. Narayan K Ghorpade

Asst. professor
BVDU CON Sangli
 Neurotic Disorders
 Neurotic, stress-related, and somatoform
disorders have common historical origin with the
concept of neurosis and association of a
substantial proportion of these disorders with
psychological causation.
 Mixtures of symptoms, especially anxiety and
depressive ones are common in these disorders
 About one fourth of the population in developed
countries will suffer from neurotic disorders
during its lifetime course.
 With the exception of social phobia their
frequency is higher in women than in men.
 Phobic Anxiety Disorders
 In agoraphobia, social and specific phobias, anxiety
is evoked predominantly by certain well-defined
situations or objects, which are external to the
individual and are not currently dangerous.
 As a result, these situations or objects are
characteristically avoided or endured with dread.
 Phobic anxiety fluctuates from mild uneasy to
terror. The individual’s concern may focus on
individual symptoms such as palpitations or feeling
faint and is often associated with secondary fears
of dying, losing control, or going mad.
 The anxiety is not relieved by the knowledge that
other people do not regard the situation in question
as dangerous or threatening.
 Agoraphobia
 „Agoraphobia“ - the fear from marketplace.
 Agoraphobia includes various phobias embracing
fears of leaving home: fears of entering shops,
crowds, and public places, or of traveling alone in
trains, buses, underground or planes.
 The lack of an immediately available exit is one of
the key features of many agoraphobic situations.
 The avoidance behaviour causes sometimes that the
sufferer becomes completely housebound.
 Most sufferers are women. Onset - early adult life.
 The lifetime prevalence - between 5—7%.
 High co-morbidity with panic disorder; depressive
and obsessional symptoms and social phobias may
be also present.
 Agoraphobia

Anticipative Fobic
Anxiety Anxiety

Specific Situation
 Social Phobias
 Clinical picture - fear of scrutiny by other people in
comparatively small groups leading to avoidance of
social situations
 The fears may be
• discrete - restricted to eating in public, to be introduced to
other people, to public speaking, or to encounters with the
opposite sex
• diffuse - social situations outside the family circle.
 Direct eye-to-eye confrontation may be stressful.
 Low self-esteem and fear of criticism.
 Symptoms may progress to panic attacks.
 Avoidance - almost complete social isolation.
 Usually start in childhood or adolescence.
 Estimation of lifetime prevalence - between 10-13 %.
 It is equally common in both sexes.
 Secondary alcoholism.
 Social Phobias

Anticipative
Fobic
Anxiety
Anxiety

Social Stress
 Specific (Isolated) Phobias
1. Fears of proximity to particular animals
• spiders (arachnophobia)
• insects (entomophobia)
• snakes (ophidiophobia)
2. Fears of specific situations such as
• heights (acrophobia)
• thunder (keraunophobia)
• darkness (nyctophobia)
• closed spaces (claustrophobia)
3. Fears of diseases, injuries or medical examinations
• visiting a dentist
• the sight of blood (hemophobia) or injury (pain —
odynophobia)
• the fear of exposure to venereal diseases (syphilidophobia)
or AIDS-phobia.
 Usually arise in childhood or early adult life and can
persist for decades if they remain untreated.
 Lifetime prevalence - between 10-20%.
 Panic Disorder
 The essential features are recurrent attacks of severe anxiety
(panic attacks) which are not restricted to any particular
situation or set of circumstances.
 Typical symptoms are palpitations, chest pain, choking
sensations, dizziness, and feelings of unreality
(depersonalisation or derealization).
 Individual attacks usually last for minutes only. The frequency
of attacks varies substantially.
 Frequent and predictable panic attacks produce fear of being
alone or going into public places.
 The afflicted persons used to think that they got a serious
somatic disease.
 The course of panic disorder is long-lasting and is complicated
with various comorbidities, in half of the cases with
agoraphobia.
 The estimation of lifetime prevalence moves between 1-3%.
Panic Disorder

Panic Anticipative
Attac Anxiety
 General Anxiety Disorder
 The essential feature is anxiety lasting more than 6 months,
which is generalized and persistent but not restricted to, or
even strongly predominating in, any particular environmental
circumstances.
 Symptoms: continuous feelings of nervousness, trembling,
muscular tension, sweating, lightheadedness, palpitations,
dizziness, and epigastric discomfort.
 Fears that the patient or a relative will shortly become ill or
have an accident are often expressed, together with a variety
of other worries and forebodings.
 The estimation of lifetime prevalence moves between 4-6 %.
 This disorder is more common in women, and often related to
chronic environmental stress.
 Its course uses to be fluctuating and chronic connected with
symptoms of frustration, sadness and complicated with abuse
of alcohol and other illicit drugs.
 Mixed Anxiety and Depressive
Disorder
 Symptoms of both anxiety and depression
are present, but neither of symptoms,
considered separately, is sufficiently
severe to justify a diagnosis of depressive
episode or specific anxiety disorder.
 Some autonomic symptoms, such as
tremor, palpitations, dry mouth, stomach
churning, must be present.
 Individuals with this mixture of
comparatively mild symptoms are
frequently seen in primary care.
 Etiology of Anxiety Disorders
 The etiology of anxiety disorders is not exactly
known.
 Genetic factors were found to play a role.
 Nongenetic factors, such as various stressful life
events during early or later stages of ontogenesis
were thought to be even more important.
 Several different neurotransmitter systems have
been implicated in these disorders, including the
noradrenergic, GABA, and serotoninergic systems
in some parts of the brain.
 The role of CO2 in the etiology of panic disorder is
seriously discussed.
 Clinical Management of Anxiety
Disorders
 Treatment of anxiety disorders:
• various psychotherapeutic techniques
 cognitive-behavioural therapy (CBT)
 psychodynamic approaches
• psychopharmacotherapy
 benzodiazepines (alprazolam, clonazepam) - for several weeks
(potential for abuse, development of tolerance and addiction)
 Buspirone - little abusive potential; especially GAD, not effective in
panic disorder; longer use is necessary
 beta-blocking drugs - for the short treatment of performance
anxiety, especially somatic symptoms like tremor
 antihistaminics
 various types of antidepressants - SRIs (clomipramine, citalopram,
fluoxetine, fluvoxamine, paroxetitle, sertraline), MOAIs
(tranylcypromifle), RIMA (moclobemide) and SNRI (venlafaxine);
well tolerated, no abuse potential

 Recommendation: to start the treatment with a brief

course of benzodiazepines as well as with
antidepressants for a longer period and to combine the
drug treatment with various types of psychotherapy.
 Commonly Used Anxiolytics
Drug Commonly used Elimination halftime
dosage (mg) (hours)
Alprazolam 0,5-6 12-15
Bromazepam 3-15 12
Diazepam 5-30 24-72
Chfordiazepoxied 10-50 24-100
Clobazam 20-30 20
Clonazepam 1-8 34
Clorazepate 15-60 60
Lorazepam 1-4 11-13
Medazepam 10-30 29
Oxazepam 30-90 4-20
Tofizopam 50-300 6
Buspirone 20-30 2-11
Hydroxyzine 300-400 12-20
 Obsessive-Compulsive Disorder
(OCD)
 Obsessional thought are ideas, images or impulses that enter
the individual’s mind again and again in a stereotyped form.
 They are recognized as the individual’s own thoughts, even
though they are involuntary and often repugnant. Common
obsessions include fears of contamination, of harming other
persons or sinning against God.
 Compulsions are repetitive, purposeful, and intentional
behaviours or mental acts performed in response to obsessions
or according to certain rule that must be applied rigidly.
Compulsions are meant to neutralize or reduce discomfort or to
prevent a dreaded event or situation.
 Autonomic anxiety symptoms are often present.
 There is very frequent comorbidity with depression (about 80%)
- suicidal thoughts. Obsessive-compulsory symptoms may
appear in early stages of schizophrenia.
 The life time prevalence: 2 - 3%. Equally common in men and
women. The course is variable and more likely to be chronic.
 Etiology of OCD
 The neurobiological model has received widespread
support in the past decade. OCD occurs more often
in persons who have various neurological disorders,
including cases of head trauma, epilepsy,
Sydenham’s and Huntington’s chorea. OCD has also
been linked to birth injury, abnormal EEG findings,
abnormal auditory evoked potentials, growth delays,
and abnormalities in neuropsychological test results.
Recently, a type of OCD has been identified in
children after a group A beta-streptococcal infection.
 The most widely studied biochemical model has
focused on the neurotransmitter serotonin because
SRIs are effective in treating patients with OCD.
 Brain imaging studies have provided some evidence
of basal ganglia involvement in persons with OCD.
 Clinical Management
 The treatment of OCD has traditionally been viewed
as difficult and unsatisfactory. Recent developments
have changed this picture substantially.

 Pharmacotherapy
• antidepressants influencing the central serotoninergic
system (clomipramine and SSRIs); higher doses of the
drugs are required to treat OCD than depression, and
response is often delayed.
 Cognitive-behaviour therapy
 Family therapy
 Patient support groups
 Psychosurgery (e.g. stereotactic cingulotomy)
 Epidemiology

30 28,7
The Lifetime Prevalence

25
20
(%)

15 13,3
11,3
10
7,6
5,3 5,1
5 3,5

0
All Anxiety Social Specific PTSD Agorafobia GAD Panic
Disorders Phobias Phobias without Disorders
Panic

Kessler et al., 1995

 Dissociative (Conversion)
Disorders
 The common theme shared by dissociative disorders
is a partial or complete loss of the normal
integration between memories of the past,
awareness of identity and immediate sensations,
and control of bodily movements. There is normally
a considerable degree of conscious control over the
memories and sensations that can be selected for
immediate attention, and the movements that are
to be carried out.
 The term “conversion hysteria” should be avoided,
because it is confusing and stigmatizing.
 The prevalence is not exactly known (up to 10%) .
 Sudden onset and termination of dissociative states.
 There are several forms of dissociative syndromes.
 Dissociative Amnesia
 The main feature is loss of memory, usually of
important recent event, which is not due to organic
mental disorder and is too extensive to be
explained by ordinary forgetfulness or fatigue.
 The amnesia is usually centered on traumatic
events, such as accidents, combat experiences, or
unexpected bereavements, and used to be partial
and selective.
 The amnesia typically develops suddenly and can
last from minutes to days.
 Differential diagnosis: complicated; it is necessary
to rule out all organic brain disorders as well as
various intoxications. The most difficult
differentiation is from conscious simulation -
malingering.
 Dissociative Stupor
 The individual suffers from diminution or absence of
voluntary movement and normal responsiveness to
external stimuli such as light, noise, and touch.
 The person lies or sits largely motionless for long
periods of time.
 Speech and spontaneous and purposeful movement
are completely absent.
 Muscle tone, posture, breathing, and sometimes
eye-opening and coordinated eye movements are
such that it is clear that the individual is neither
asleep nor unconscious.
 Positive evidence of psychogenic causation in the
form of either recent stressful events or prominent
interpersonal or social problems.
 Trance and Possession
Disorders
 There is a temporary loss of both the
sense of personal identity and full
awareness of the surroundings. The
individual can act as if taken over by
another personality, spirit, deity, or
“force”. Repeated sets of
extraordinary movements, postures,
and utterances can be observed.
 Dissociative Disorders of
Movement and Sensation
 There is a loss of or interference with movements or loss of
sensations (usually cutaneous). Mild and transient varieties of
these disorders are often seen in adolescence, particularly in
girls, but the chronic varieties are usually found in young adults.
 Dissociative motor disorders
 Dissociative convulsions
 Dissociative anaesthesia
 Ganser’s syndrome – „approximate” or grossly incorrect answers
 Multiple personality disorder means the apparent existence of
two or more distinct personalities within an individual, with only
one of them being evident at a time (Mr. Jekyl and Mr. Hyde).
Each personality is complete, with its own memories,
behaviours, and preferences, but neither has access to the
memories of the other and the two are almost always unaware
of each other’s existence. Change from one personality to
another is in the first instance usually sudden and closely
associated with traumatic events.
 Clinical Management
 Psychotherapy is a method of choice of
treatment of dissociative disorders (e.g.
psychodynamic programs, hypnosis).
 Medications have no proven value with
exception of sodium amobarbital
interview.
 Post-traumatic Stress Disorder
(PTSD)
 PTSD is a delayed and/or protracted response to a stressful
event of an exceptionally threatening or catastrophic nature.
 The three major elements of PTSD include
1) reexperiencing the trauma through dreams or recurrent and
intrusive thoughts (“flashbacks”)
2) showing emotional numbing such as feeling detached from others
3) having symptoms of autonomic hyperarousal such as irritability
and exaggerated startle response, insomnia
 Commonly there is fear and avoidance of cues that remind the
sufferer of the original trauma. Anxiety and depression are
commonly associated with the above symptoms. Excessive use
of alcohol and drugs may be a complicating factor.

 The onset follows the trauma with a latency period, which may
range from several weeks to months, but rarely more than half
a year.
 The lifetime prevalence is estimated at about 0.5% in men and
1.2% in women.
Post-traumatic Stress Disorder
(PTSD)
Acute Flashback
Reaction
on Trauma

Trauma
 Clinical Management
 Pharmacological approach:
• antidepressant medication
• short-term benzodiazepines trials
• mood stabilizers (carbamazepine, valproate)
• antipsychotics
 Psychotherapy is also of importance - CBT
using education and exposure techniques
 Group therapy, family therapy and self-
help groups are widely recommended.
 F45 Somatoform Disorders
 Somatoform disorders - multiple, recurrent and
frequent somatic complaints requiring medical
attention without association with any physical
disorder are prominent.
 The medical history of multiple contacts with
primary care and specialized health services is
typical before the patient is referred to
psychiatric care.
 Characteristics of somatoform disorders:
1. somatic complains of many medical maladies
without association with serious demonstrable
peripheral organ disorder
2. psychological problems and conflicts that are
important in initiating, exacerbating and maintaining
the disturbance
 F45.0 Somatization Disorder
Diagnostic Guidelines
A definite diagnosis requires the presence of all of
the following:
a) at least 2 years of multiple and variable
physical symptoms for which no adequate
physical explanation has been found,
b) persistent refusal to accept the advice or
reassurance of several doctors that there is no
physical explanation for the symptoms,
c) some degree of impairment of social and family
functioning attributable to the nature of
symptoms and resulting behavior.
 F45.0 Somatization Disorder
Differential Diagnosis
 Medical conditions may be confused with
somatoform disorder especially early in their course
(multiple sclerosis, brain tumor,
hyperparathyroidism, hyperthyroidism, lupus
erythematosus).
 Further investigation or consultation should be
considered in long-term somatization disorder if
there is a shift in the emphasis or stability of the
physical complaints. This change in symptoms
suggests possible development of physical disease.
 Affective (depressive) and anxiety disorders
accompany somatization disorders but need not be
specified separately unless they are sufficiently
marked and persistent.
 F45.0 Somatization Disorder
Therapy and Prognosis
 Chronic relapsing condition starting in adolescence or even as
late as the third decade of life.
 New symptoms during the emotional distress.
 Typical episodes last 6 to 9 months; quiescent time of 9 to 12
months.
 Management strategies:
1. the trusting relationship between the patient and one (if possible)
primary care physician
2. set up regularly scheduled visits every 4 or 6 weeks
3. keep outpatient visits brief-perform at least a partial physical
examination during each visit directed at the organ system of
complaint
4. understand symptoms as emotional message rather than a sing of
new disease, look for signs of disease rather than focus on
symptom
5. avoid diagnostic tests, laboratory evaluations and operative
procedures unless clearly indicated
6. set a goal to get selected somatization patients referral- ready for
mental health care
 Group therapy (time limited, behavior oriented and structured
group).
 F45.2 Hypochondriacal Disorder
 The disorder is characterized by a persistent
preoccupation and a fear of developing or having
one or more serious and progressive physical
disorders.
 Patients persistently complain of physical problems
or are persistently preoccupied with their physical
appearance.
 The fear is based on the misinterpretation of
physical signs and sensations.
 Physician physical examination does not reveal any
physical disorder, but the fear and convictions
persist despite the reassurance.
 F45.2 Hypochondriacal Disorder
Diagnostic Guidelines
 Presence of both of the following criteria:
1.persistent belief in the presence of at least one serious
physical illness underlying the presenting symptom or
symptoms, even thought repeated investigations and
examinations have not identified any adequate physical
explanation, or a persistent preoccupation with presumed
deformity or disfigurement
2.persistent refusal to accept the advice and reassurance of
several different doctors that there is no physical illness or
abnormity underlying the symptoms
 Includes: Body dysmorphic disorder,
Dysmorphophobia (non delusional),
Hypochondriacal neurosis, Hypochondriasis,
Nosophobia
 F45.2 Hypochondriacal Disorder
Differential Diagnosis
 Basic - ruling out underlying organic disease.
 The main somatoform disorder that need to be
differentiated from hypochondriasis is
somatization disorder.
 Hypochondriasis needs to be distinguished from
factitious disorder with predominantly physical
signs and from malingering.
 F45.2 Hypochondriacal Disorder
Therapy and Prognosis
 The illness is usually long-standing, with episodes
lasting months or years. Recurrences occur
frequently after psychosocial distress.
 Higher socio-economic status, presence of other
treatable condition, anxiety and depression, an
acute onset, absence of personality disorder or
comorbid organic disease predict better outcome.
 No evidence-based treatment has been described.
 Patients strongly refuse the mental health care
professionals and remain in primary health care.
 Similar management and group therapy strategy as
in somatization disorder may be useful.
 Thank you