Neurotic Disorders for Psychiatric trainees.

1
Neurotic Disorders for Psychiatric trainees.

• Dr Keith Gilhooly
• ST5 Psychiatrist

2
General points.

• Lots of comorbidity in these disorders especially
  with depression, other neuroses, PD, and
  substance misuse
• For useful prevelance data..
• ECA. Euroupean catchment area survey. (Robins
  Regier, 1991)
• NCS. National Co morbidity study . US
• http//www.hcp.med.harvard.edu/ncs/
• See back of handout.

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Licences.( Arbitary).

• If asked pharmacological treatment for anxiety
  disorder if in doubt say SSRI Eg. PAROXETINE.
  It is licensed for
• Social anxiety, GAD, Panic disorder, OCD, PTSD
• Sertraline OCD, PTSD
• Fluoxetine OCD
• Esitalopram GAD, OCD, Panic disorder
• Dont forget emphasise patient choice

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Psychodynamic understanding of anxiety disorders.

• Focus on
• 1.Intrapsychic conflicts.
• 2.Unconcious fantasies.
• 3. Defense mechanisms
• 4. Compromise function of symptoms.

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Freud

• Freud 1926 identifies 2 types anxiety. Signal and
  traumatic.
• Signal anxiety alerts ego to Id impulses,and
  fantasies inconsistent with super ego.
• If defenses put in place by super ego ineffective
  get traumatic anxiety. (GAD, Panic disorder)

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Compromise formations

• If defense mechanism immature ego synthesises
  compromise between the wish and the defense.
• Psychiatric symptoms as well as dreams and
  further fantasies are compromise formations.
• Pleasure principle. Symptoms less distressing
  than underlying conflict.

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Neurosis as opposed to perversion

• Perversion- regress to earlier stage psychosexual
  development and hypertrophy of that drive.
• If this hypertrophied drive sufficiently
  repressed then the individual developed a
  neurosis.

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Phobias- theories

• Pavlovian (Classical/ associative) conditioning.
  An association is formed between the stimulus and
  feeling threatened. Watson shock /furry
  rabbit(1919)
• Operant conditioning.Two factor theory. Mowrer.
  Avoidance behavior that strengthens the negative
  reinforcer

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Phobias. Theories.

• Psychodynamic- displacement of anxiety from an
  unacceptable object eg self destructive impulses
  (Freud, Little Hans), onto a more acceptable
  object. Displacement projection and avoidance.
• Learning theory- vicarious and direct learning
  from others that a situation is threatening.
• Innate or prepared behaviours.

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Phobias F 40ICD 10 Diagnostic Common factors and
differences

• Phobias Seen in up to 15 of people
• Characterised by-
• Subsection A. Certain Specific thing or
  situations, not CURRENTLY dangerous.
• Fear and or Avoidance of phobic stimulus external
  to subject.

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Subsection B (12 symptoms)

• 4 Autonomic arousal
• Palpitations, sweating, shaking, dry mouth.
• 4 Chest and abdo symptoms.
• Diff breathing, choking, chest pain, nausea.
• 4 Mental state symptoms.
• Dizzy,derealisation, depersonalisation, fear
  losing control, fear dying.

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Phobias. Subsection B cotd.

• Need 2 of these for agorophobia and social
  phobia. For specific phobias number not
  specified.
• Sebsection B for social phobia additionally has,
• blushing, shaking, fear of vomiting, and
  urgency/ fear of micturition
• Subsection B also used in Dx GAD. Need 4 of them.
• Subsection B also used in panic disorder and
  suggested that all subsection B symptoms
  characteristic.

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Section C and D.

• C Significant emotional distress. Insight
  Excessive and unreasonable
• Symptoms in situation or in anticipation of it.
• Panic disorder can be secondary diagnosis to
  phobia and can indicate severity.

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Agorophobia F40.0

• With above criteria(SectionA) specific fear or
  avoidance must be of at least 2 of the following.
• Crowds
• public spaces
• travelling alone
• travel away from home.

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Agorophobia Stats

• Lifetime prevelence 2-6 across studies.
• 6 month prevelence 2.5-5.8 ECA
• MF 13
• Bimodal. Two peaks. 1. early-mid 20s.
• 2.Mid thirties.
• Therefore later than other phobias.

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Agorophobia treatment

• SSRI first choice.
• Start low but can aim high. Eg paroxetine at
  least 40mg, can go to 60 mg.(same as panic
  disorder)
• Clomipramine/Imipramine second line (unlicensed)
• MAOI or augment with Lithium.
• Mood stabiliser

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Social Phobias F40.1

• Fear or avoidance specifically of
• Focus of attention.
• Potentially embarrassing or social situations
• May be specific eg eating, vomiting, pub speaking.

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Stats

• Lifetime prevalence 2.4-13.3
• 12 month prevelence 7.9
• MF presenting for help.
• Comm survey MgtF.
• Peak 5 yrs and 11-15 yrs.
• MZ/DZ 24.415.3???genetic predisposition to
  interpret things as dangerous.

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Social phobia. Teatment

• As usual CBT. Could be group setting.
• Social skills training.
• Modelling and graded exposure.
• SSRI/ . Evidence for paroxetine, fluvoxamine and
  sertraline and MAOI.

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Social phobia. Treatment

• Paroxetine and escitalopram licensed.
• Response rates up to 90 with combined
  approaches.
• B-blockers. Only evidence that they help with
  short term control of tremor and palpitations

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Simple Phobias

• Phobia associated with single stimulus eg
  spiders, flying etc
• Lifetime prevelence 11.3
• Onset usually childhood with MF
• As adults is FgtM (31-201)
• Mean onset 15 years. Animal phobias 7 years
• Childhood- usually environmental eg animals
• Adult- usually situational eg places

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Treatment.CBT

• Systemic desensitisation. Graded exposure
• Reciprocal inhibition. Relaxation (Wolpe)
• Modelling
• Avoidance is safety behaviour that results in
  negative re enforcement.
• Cognitive distortions related to negative re
  enforcement. If I am anxious it must be
  dangerous

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Treatments CBT

• Modelling
• Implosion
• Flooding no better than graded exposure.

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• Psychodynamic. ??? What conflict symptoms
  represent. Repressed impulses brought to
  counciousness. Little Hans (Freud)
• Medications-generally not used

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Some unusual Phobias

• Pogonophobia -Beards
• Bogyphobia -Bogeyman
• Panophobia -Everything
• Syngenesophobia -Relatives
• ??Hippopotomonstrosesquippedaliophobia.
  -Long words

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Phobic Disorders..
Phobia of phobias FM Age of onset
Agora 60 2-31 15-35
Social 8 11 presenting for help 13-20
Simple 17 3-201 Childhood
Illness 15 FM ?
OCD - FM 20
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Panic Disorder

• 4 non-situational panic attacks over 4/52
• May be non-fear in 10 ie dont describe
  feeling fearful.
• Descrete, abrupt, reaches max after a few
  minutes.
• Same list autonomic, chest, and mental state
  symptoms.

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Panic Disorder Stats.

• Lifetime prevelence 4.2 (ECA, NCS)
• MF 12-3
• Peaks 15-24, 45-54.
• Co morbidity with agorophobia 75 Psyche clinic.
• In ICD 10 primary diagnosis would be agorophobie.
  In DSM, other way round

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Panic Disorder

• Probably imbalance of NA5HT in caudate nucleus
• May be linked to childhood respiratory disorders
  (suffocation alarm)
• Highly comorbid (depression (50), ETOH (40),
  OCD, phobias, somatisation)

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Panic Disorder treatment.

• NICE Guidelines 2004.Patient choice.Restricted
  Meds and or CBT
• SSRI first choice. Clomipramine/Imipramine second
  line (unlicensed,70-80 effective)
• Start low but can aim high. Eg paroxetine can go
  to 60 mg.

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CBT.

• Teach about body responses? Thinking errors about
  dying.
• Relaxation techniques
• Control hyperventilation

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Generalised Anxiety Disorder F41.1

• A. Non situational anxiety on most days for 6
  months.
• Need 4 symptoms from subsection B. One of these
  must be from autonomic arousal section.
• Subsection B for GAD has added general and non
  specific symptoms also.

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• Lifetime prevelence (NCS)3-4
• FM 21
• Mean onset 21.(Range 2-60 yrs)
• 50 also depressed
• Only 1/3 seek help
• Genetic heritability 30

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Neurobiology

• Loss regulatory control HPA axis.
• Dex sup test reduced cortisol supression.
• Decrease GABA
• Dysregulation 5-HT system.
• Sustained activation stria terminalis after
  prolonged CRF. Increase startle response.

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Cognitive model (Dugas 2004)

• Belief that worry keeps you safe (Prepared)
• Cannot tolerate uncertainty.
• Search for perfect solutions leads to failure and
  further worry.
• ?? Worry inhibits emotional processing that is
  more distressing

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• GAD adults report reverse parenting
• Unpredictability of outcomes
• Cold, over controling parents.
• Sensitised to needs of others. (To stay safe in
  childhood)
• Child learns to inhibit own emotional experience
  and rely on anticipatory problem solving
• Rank high on empathy and worry about
  interpersonal issues

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Treatment.

• NICE patient choice.
• Some evidence that CBT works.
• SSRI. Paroxetine licenced.Same titration as for
  depression (BNF)
• Venlafaxine 75 mg od. Discontinue if no response
  after 12 weeks.
• Imipramine and clomipramine

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Obsessive Compulsive Disorder

• Recurrent, intrusive, unpleasant thought,
  feelings, images or impulses (obsessions) /-
  compulsive behaviours (aim at reducing anxiety)
• Must be senseless to patient, resisted, internal,
  and under own control ie not imposed from
  external source.
• Most common obsessions are contamination and
  doubts
• Most common compulsions are checking and cleaning

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OCD

• Affects 2-3
• Onset in 20s
• FM
• Often comorbid with 2/3 depressed and ¼ socially
  phobic
• Often delay 5-10 years before seeking help
• Shopping, gambling, eating not OCD as behaviour
  is ego-syntonic ie pleasant

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OCD

• Worse outcome if early onset, bizarre obsessions,
  overvalued ideas and always yield to the
  compulsion
• Treat with CBT- exposure to stimulus with
  response prevention, loop tapes.
• Medication- SSRIs, clomipramine
• Best is combination- meds CBT.
• Psychosurgery in extreme cases

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Psychodynamic Theory

• Similar to phobias. Id impulses and fantasies in
  conflict with excessive super ego.
• Defense of magical undoing in compulsions to make
  reparation for phantasised destructiveness.
• Intellectualisation leads to pre occupation and
  and thus avoidance of conflict.
• Therapy. Deal with issues of control. Loosen
  excessive super-ego.

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CBT

• (Salkovskis). Intrusive thoughts normal.
• Those with OCD have increased sense of
  responsibility and self blaming belief systems
  (Core assumptions) that trigger secondary NATs.
• CA may be Only immoral people have such
  thoughts
• Exaggerated sense of responsibility.
• Rather than dismiss thought end up ritualising to
  undo.

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• Thought Action
• Failing to prevent harm causing harm.
• No attenuation of concern by low probability

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Adjustment Disorders

• Maladaptive response to a stressor that
  interferes with functioning
• Includes bereavement and adjustment to medical
  disorders eg occurs in 5 after medical admission
• FM 21, any age

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Acute Stress Reaction

• Occurs following exceptional stress
• Lasts hours to days
• May involve anger, depression and withdrawal.
• Resolves on removing the stressor

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Post Traumatic Stress Disorder

• Affects 1-5 (more subclinical)
• Event is perceived as life threatening often with
  helplessness
• Involves-
• Reliving the event
• Avoiding things associated with the event
• Increased arousal eg anxiety
• Numbing of response eg anhedonia

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PTSD

• Aetiology- Cognitive processing model- lack of
  processing due to being overwhelmed by the
  emotional value of the event (level of processing
  theory)
• Treat with CBT and meds (SSRIs).
• Also eye movement desensitisation and
  reprogramming (EMDR therapy), hypnotherapy and
  analytical psychotherapy.

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Somatoform Disorders

• Characterised by physical symptoms persisting
  despite negative findings
• Somatisation disorder (Briquets syndrome)-
  multiple, variable sx in different systems for gt2
  years. Uncommon (0,1-0,2) with FM 201.
• Onset in teens to 20s
• High comorbidity

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Somatoform Disorders

• Hypochondriacal disorder- focus is that mild
  symptoms indicate serious disease
• Includes body dysmorphic disorder
• Affects 5 with FM, onset 20-30s
• 80 also depressed/anxious.

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Dissociative/ Conversion Disorders

• Loss of integration of memories, control of body
  and identity with a psychological cause
  (previously called hysterical reaction)
• Allow a patient to avoid direct expression of
  distress- ie distress is expressed as physical
  symptom
• Up to 20 have histrionic PD

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Dissociative Disorders

• Dissociative disorders of movement and sensation
  of psychological cause- usually accompanied by
  belle indifference (a seeming to not care
  about the symptoms).
• Dissociative amnesia- patchy loss of memory for
  unpleasant events
• Dissociative fugue- amnesia with a purposeful
  journey away from home with maintained self care

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Dissociative Disorders

• Underlying physical cause found in 1-2/3 (be
  cautious not to miss!)
• FM 2-51 often with Fhx.
• Onset as young adult
• Ruralgturban (odd) and low SE class
• 90 resolve in 1/12

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Depersonalisation/ derealisation

• A subjective as if phenomena that things are
  remote, unreal and automatised with intact
  insight
• Often fleeting and may be normal
• May decrease anxiety but is unpleasant
• Usually part of another disorder eg anxiety or
  depression
• FM 21