Emotional stress and psychical trauma. Neurotic Disorders Neurotic, stress-related, and somatoform disorders have common historical origin with the concept.

Emotional stress and Emotional stress and psychical traumapsychical trauma

Neurotic DisordersNeurotic Disorders

Neurotic, stress-related, and somatoform Neurotic, stress-related, and somatoform disorders have common historical origin with the disorders have common historical origin with the concept of neurosis and association of a concept of neurosis and association of a substantial proportion of these disorders with substantial proportion of these disorders with psychological causation.psychological causation.

Mixtures of symptoms, especially anxiety and Mixtures of symptoms, especially anxiety and depressive ones are common in these disorders depressive ones are common in these disorders

About one fourth of the population in developed About one fourth of the population in developed countries will suffer from neurotic disorders countries will suffer from neurotic disorders during its lifetime course.during its lifetime course.

With the exception of social phobia their With the exception of social phobia their frequency is higher in women than in men.frequency is higher in women than in men.

Neurotic, Stress-Related and Neurotic, Stress-Related and Somatoform Disorders (F40-F48) Somatoform Disorders (F40-F48)

F40 Phobic anxiety disorders F40 Phobic anxiety disorders

F41 Other anxiety disorders F41 Other anxiety disorders

F42 Obsessive-compulsive disorder F42 Obsessive-compulsive disorder

F43 Reaction to severe stress, and F43 Reaction to severe stress, and adjustment disorders adjustment disorders

F44 Dissociative [conversion] F44 Dissociative [conversion] disorders disorders

F45 Somatoform disorders F45 Somatoform disorders

F48 Other neurotic disorders F48 Other neurotic disorders

F40F40 Phobic anxiety disordersPhobic anxiety disorders

F40 F40 Phobic anxiety disorders Phobic anxiety disorders

F40.0F40.0 Agoraphobia Agoraphobia

F40.1F40.1 Social phobias Social phobias

F40.2F40.2 Specific (isolated) phobias Specific (isolated) phobias

F40.8F40.8 Other phobic anxiety disorders Other phobic anxiety disorders

F40.9F40.9 Phobic anxiety disorder, Phobic anxiety disorder, unspecified unspecified

Phobic Anxiety DisordersPhobic Anxiety Disorders In agoraphobia, social and specific phobias, anxiety In agoraphobia, social and specific phobias, anxiety

is evoked predominantly by certain well-defined is evoked predominantly by certain well-defined situations or objects, which are external to the situations or objects, which are external to the individual and are not currently dangerous.individual and are not currently dangerous.

As a result, these situations or objects are As a result, these situations or objects are characteristically avoided or endured with dread.characteristically avoided or endured with dread.

Phobic anxiety fluctuates from mild uneasy to Phobic anxiety fluctuates from mild uneasy to terror. The individual’s concern may focus on terror. The individual’s concern may focus on individual symptoms such as palpitations or feeling individual symptoms such as palpitations or feeling faint and is often associated with secondary fears faint and is often associated with secondary fears of dying, losing control, or going mad. of dying, losing control, or going mad.

The anxiety is not relieved by the knowledge that The anxiety is not relieved by the knowledge that other people do not regard the situation in question other people do not regard the situation in question as dangerous or threatening.as dangerous or threatening.

AgoraphobiaAgoraphobia „„Agoraphobia“ - the fear from marketplace.Agoraphobia“ - the fear from marketplace. AgoraphobiaAgoraphobia includes various phobias embracing includes various phobias embracing

fears of leaving home: fears of leaving home: fears of entering shops, fears of entering shops, crowds, and public places, or of traveling alone in crowds, and public places, or of traveling alone in trains, buses, underground or planes.trains, buses, underground or planes.

The lack of an immediately available exit is one of The lack of an immediately available exit is one of the key features of many agoraphobic situations.the key features of many agoraphobic situations.

The avoidance behaviour causes sometimes that the The avoidance behaviour causes sometimes that the sufferer becomes completely housebound.sufferer becomes completely housebound.

Most sufferers are women. Onset - early adult life.Most sufferers are women. Onset - early adult life. The lifetime prevalence - between 5—7%.The lifetime prevalence - between 5—7%. High co-morbidity with panic disorder; depressive High co-morbidity with panic disorder; depressive

and obsessional symptoms and social phobias may and obsessional symptoms and social phobias may be also present.be also present.

Agoraphobia Agoraphobia

Specific Situation

Fobic Anxiety

Anticipative Anxiety

Social PhobiasSocial Phobias Clinical picture - fear of scrutiny by other people in Clinical picture - fear of scrutiny by other people in

comparatively small groups leading to avoidance of comparatively small groups leading to avoidance of social situationssocial situations

The fears may beThe fears may be• discrete - restricted to eating in public, to be introduced to discrete - restricted to eating in public, to be introduced to

other people, to public speaking, or to encounters with the other people, to public speaking, or to encounters with the opposite sexopposite sex

• diffuse - social situations outside the family circle.diffuse - social situations outside the family circle. Direct eye-to-eye confrontation may be stressful.Direct eye-to-eye confrontation may be stressful. Low self-esteem and fear of criticism. Low self-esteem and fear of criticism. Symptoms may progress to panic attacks. Symptoms may progress to panic attacks. Avoidance - almost complete social isolation.Avoidance - almost complete social isolation. Usually start in childhood or adolescence. Usually start in childhood or adolescence. Estimation of lifetime prevalence - between 10-13 %.Estimation of lifetime prevalence - between 10-13 %. It is equally common in both sexes. It is equally common in both sexes. Secondary alcoholismSecondary alcoholism..

Social PhobiasSocial Phobias

Fobic Anxiety

Anticipative Anxiety

Social Stress

Specific (Isolated) PhobiasSpecific (Isolated) Phobias1.1. Fears of proximity to particular animalsFears of proximity to particular animals

• spiders spiders ((arachnophobiaarachnophobia))• insectsinsects ( (entomophobiaentomophobia))• snakes snakes ((ophidiophobia)ophidiophobia)

2.2. Fears of specific situations such asFears of specific situations such as• heights (acrophobia)heights (acrophobia)• thunder (keraunophobia)thunder (keraunophobia)• darkness (nyctophobia)darkness (nyctophobia)• closed spaces (claustrophobia)closed spaces (claustrophobia)

3.3. Fears of diseases, injuries or medical examinationsFears of diseases, injuries or medical examinations• visiting a dentistvisiting a dentist• the sight of blood (hemophobia) or injury (pain —the sight of blood (hemophobia) or injury (pain —

odynophobia)odynophobia)• the fear of exposure to venereal diseases (syphilidophobia) the fear of exposure to venereal diseases (syphilidophobia)

or AIDS-phobia.or AIDS-phobia. Usually arise in childhood or early adult life and can Usually arise in childhood or early adult life and can

persist for decades if they remain untreated. persist for decades if they remain untreated. Lifetime prevalence - between 10-20%.Lifetime prevalence - between 10-20%.

F41 Other Anxiety DisordersF41 Other Anxiety Disorders

F41 F41 Other anxiety disordersOther anxiety disorders

F41.0F41.0 Panic disorder Panic disorder ((episodic episodic paroxysmal anxietyparoxysmal anxiety))

F41.1F41.1 Generalized anxiety disorder Generalized anxiety disorder

F41.2F41.2 Mixed anxiety and depressive Mixed anxiety and depressive disorder disorder

F41.3F41.3 Other mixed anxiety disorders Other mixed anxiety disorders

F41.8F41.8 Other specified anxiety disorders Other specified anxiety disorders

F41.9F41.9 Anxiety disorder, unspecified Anxiety disorder, unspecified

Other Anxiety DisordersOther Anxiety Disorders

Manifestations of anxiety are also the Manifestations of anxiety are also the major symptoms of these disorders, major symptoms of these disorders, however, it is not restricted to any however, it is not restricted to any particular environmental situation.particular environmental situation.

Panic DisorderPanic Disorder The essential features are recurrent attacks of severe anxiety The essential features are recurrent attacks of severe anxiety

(panic attacks) which are not restricted to any particular (panic attacks) which are not restricted to any particular situation or set of circumstances. situation or set of circumstances.

Typical symptoms are Typical symptoms are palpitations, chest pain, choking palpitations, chest pain, choking sensations, dizziness, and feelings of unrealitysensations, dizziness, and feelings of unreality (depersonalisation or derealization). (depersonalisation or derealization).

Individual attacks usually last for minutes only. The frequency Individual attacks usually last for minutes only. The frequency of attacks varies substantially.of attacks varies substantially.

Frequent and predictable panic attacks produce fear of being Frequent and predictable panic attacks produce fear of being alone or going into public places. alone or going into public places.

The afflicted persons used to think that they got a serious The afflicted persons used to think that they got a serious somatic disease.somatic disease.

The course of panic disorder is long-lasting and is complicated The course of panic disorder is long-lasting and is complicated with various comorbidities, in half of the cases with with various comorbidities, in half of the cases with agoraphobia.agoraphobia.

The estimation of lifetime prevalence moves between 1-3%.The estimation of lifetime prevalence moves between 1-3%.

Panic DisorderPanic Disorder

Panic Attac

Anticipative Anxiety

General Anxiety DisorderGeneral Anxiety Disorder The essential feature is anxiety lasting more than 6 months, The essential feature is anxiety lasting more than 6 months,

which is generalized and persistent but not restricted to, or which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental even strongly predominating in, any particular environmental circumstances.circumstances.

Symptoms: Symptoms: continuous feelings of nervousness, trembling, continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, muscular tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfortdizziness, and epigastric discomfort..

Fears that the patient or a relative will shortly become ill or Fears that the patient or a relative will shortly become ill or have an accident are often expressed, together with a variety have an accident are often expressed, together with a variety of other worries and forebodings.of other worries and forebodings.

The estimation of lifetime prevalence moves between 4-6 %.The estimation of lifetime prevalence moves between 4-6 %. This disorder is more common in women, and often related to This disorder is more common in women, and often related to

chronic environmental stress. chronic environmental stress. Its course uses to be fluctuating and chronic connected with Its course uses to be fluctuating and chronic connected with

symptoms of frustration, sadness and complicated with abuse symptoms of frustration, sadness and complicated with abuse of alcohol and other illicit drugs.of alcohol and other illicit drugs.

Mixed Anxiety and Depressive Mixed Anxiety and Depressive DisorderDisorder

Symptoms of both anxiety and depression Symptoms of both anxiety and depression are present, but neither of symptoms, are present, but neither of symptoms, considered separately, is sufficiently considered separately, is sufficiently severe to justify a diagnosis of depressive severe to justify a diagnosis of depressive episode or specific anxiety disorder.episode or specific anxiety disorder.

Some autonomic symptoms, such as Some autonomic symptoms, such as tremor, palpitations, dry mouth, stomach tremor, palpitations, dry mouth, stomach churning, must be present.churning, must be present.

Individuals with this mixture of Individuals with this mixture of comparatively mild symptoms are comparatively mild symptoms are frequently seen in primary care.frequently seen in primary care.

Etiology of Anxiety DisordersEtiology of Anxiety Disorders The etiology of anxiety disorders is not exactly The etiology of anxiety disorders is not exactly

known.known. Genetic factors were found to play a role.Genetic factors were found to play a role. Nongenetic factors, such as various stressful life Nongenetic factors, such as various stressful life

events during early or later stages of ontogenesis events during early or later stages of ontogenesis were thought to be even more important. were thought to be even more important.

Several different neurotransmitter systems have Several different neurotransmitter systems have been implicated in these disorders, including the been implicated in these disorders, including the noradrenergic, GABA, and serotoninergic systems noradrenergic, GABA, and serotoninergic systems in some parts of the brain.in some parts of the brain.

The role of COThe role of CO22 in the etiology of panic disorder is in the etiology of panic disorder is seriously discussed.seriously discussed.

Clinical Management of Anxiety Clinical Management of Anxiety DisordersDisorders

Treatment of anxiety disorders:Treatment of anxiety disorders:• various psychotherapeutic techniquesvarious psychotherapeutic techniques

cognitive-behavioural therapy (CBT)cognitive-behavioural therapy (CBT) psychodynamic approachespsychodynamic approaches

• psychopharmacotherapypsychopharmacotherapy benzodiazepinesbenzodiazepines (alprazolam, clonazepam) - for several weeks (alprazolam, clonazepam) - for several weeks

(potential for abuse, development of tolerance and addiction) (potential for abuse, development of tolerance and addiction) BuspironeBuspirone - little abusive potential; especially GAD, not effective in - little abusive potential; especially GAD, not effective in

panic disorder; longer use is necessarypanic disorder; longer use is necessary beta-blocking drugsbeta-blocking drugs - for the short treatment of performance - for the short treatment of performance

anxiety, especially somatic symptoms like tremoranxiety, especially somatic symptoms like tremor antihistaminicsantihistaminics various types of various types of antidepressantsantidepressants - SRIs (clomipramine, citalopram, - SRIs (clomipramine, citalopram,

fluoxetine, fluvoxamine, paroxetitle, sertraline), MOAIs fluoxetine, fluvoxamine, paroxetitle, sertraline), MOAIs (tranylcypromifle), RIMA (moclobemide) and SNRI (venlafaxine); (tranylcypromifle), RIMA (moclobemide) and SNRI (venlafaxine); well tolerated, no abuse potentialwell tolerated, no abuse potential

RecommendationRecommendation: to start the treatment with a brief : to start the treatment with a brief course of benzodiazepines as well as with course of benzodiazepines as well as with antidepressants for a longer period and to combine the antidepressants for a longer period and to combine the drug treatment with various types of psychotherapy.drug treatment with various types of psychotherapy.

Commonly Used AnxiolyticsCommonly Used AnxiolyticsDrug Commonly used

dosage (mg)Elimination halftime

(hours)Alprazolam 0,5-6 12-15Bromazepam 3-15 12Diazepam 5-30 24-72Chfordiazepoxied 10-50 24-100Clobazam 20-30 20Clonazepam 1-8 34Clorazepate 15-60 60Lorazepam 1-4 11-13Medazepam 10-30 29Oxazepam 30-90 4-20Tofizopam 50-300 6Buspirone 20-30 2-11Hydroxyzine 300-400 12-20

F42 Obsessive-Compulsive F42 Obsessive-Compulsive Disorder (OCD)Disorder (OCD)

F42 F42 Obsessive-compulsive disorderObsessive-compulsive disorder F42.0F42.0 Predominantly obsessional Predominantly obsessional

thoughts or ruminations thoughts or ruminations F42.1F42.1 Predominantly compulsive acts Predominantly compulsive acts

((obsessional ritualsobsessional rituals))F42.2F42.2 Mixed obsessional thoughts and Mixed obsessional thoughts and

acts acts F42.8F42.8 Other obsessive-compulsive Other obsessive-compulsive

disorders disorders F42.9F42.9 Obsessive-compulsive disorder, Obsessive-compulsive disorder,

unspecified unspecified

Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder (OCD)(OCD)

ObsessionalObsessional thought are ideas, images or impulses that enter thought are ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form. the individual’s mind again and again in a stereotyped form.

They are recognized as the individual’s own thoughts, even They are recognized as the individual’s own thoughts, even though they are involuntary and often repugnant. Common though they are involuntary and often repugnant. Common obsessions include fears of contamination, of harming other obsessions include fears of contamination, of harming other persons or sinning against God.persons or sinning against God.

CompulsionsCompulsions are repetitive, purposeful, and intentional are repetitive, purposeful, and intentional behaviours or mental acts performed in response to obsessions behaviours or mental acts performed in response to obsessions or according to certain rule that must be applied rigidly. or according to certain rule that must be applied rigidly. Compulsions are meant to neutralize or reduce discomfort or to Compulsions are meant to neutralize or reduce discomfort or to prevent a dreaded event or situation.prevent a dreaded event or situation.

Autonomic anxiety symptoms are often present.Autonomic anxiety symptoms are often present. There is very frequent comorbidity with depression (about 80%) There is very frequent comorbidity with depression (about 80%)

- suicidal thoughts. Obsessive-compulsory symptoms may - suicidal thoughts. Obsessive-compulsory symptoms may appear in early stages of schizophrenia.appear in early stages of schizophrenia.

The life time prevalenceThe life time prevalence:: 2 2 - - 3%. 3%. EEqually common in men and qually common in men and women. The course is variable and more likely to be chronic.women. The course is variable and more likely to be chronic.

EEtiology of OCDtiology of OCD The The neurobiological modelneurobiological model has received widespread has received widespread

support in the past decade. OCD occurs more often in support in the past decade. OCD occurs more often in persons who have various neurological disorders, persons who have various neurological disorders, including cases of head trauma, epilepsy, including cases of head trauma, epilepsy, Sydenham’s and Huntington’s chorea. OCD has also Sydenham’s and Huntington’s chorea. OCD has also been linked to birth injury, abnobeen linked to birth injury, abnormrmal EEG findings, al EEG findings, abnormal auditory evoked potentials, growth delays, abnormal auditory evoked potentials, growth delays, and abnormalities in neuropsychological test results. and abnormalities in neuropsychological test results. Recently, a type of OCD has been identified in Recently, a type of OCD has been identified in children after a group A beta-streptococcal infection. children after a group A beta-streptococcal infection.

The most widely studied biochemical model has The most widely studied biochemical model has focused on the neurotransmitter focused on the neurotransmitter serotoninserotonin because because SRIs are effective in treating patients with OCD. SRIs are effective in treating patients with OCD.

Brain imaging studies have provided some evidence Brain imaging studies have provided some evidence of basal ganglia involvement in persons with OCD.of basal ganglia involvement in persons with OCD.

Clinical ManagementClinical Management The treatment of OCD has traditionally been viewed The treatment of OCD has traditionally been viewed

as difficult and unsatisfactory. Recent developments as difficult and unsatisfactory. Recent developments have changed this picture substantially. have changed this picture substantially.

PharmacotherapyPharmacotherapy• antidepressants influencing the central serotoninergic antidepressants influencing the central serotoninergic

system (clomipramine and SSRIs); higher doses of the drugs system (clomipramine and SSRIs); higher doses of the drugs are required to treat OCD than depression, and response is are required to treat OCD than depression, and response is often delayed. often delayed.

Cognitive-behaviour therapyCognitive-behaviour therapy Family therapyFamily therapy Patient support groupsPatient support groups Psychosurgery (e.g. stereotactic cingulotomy)Psychosurgery (e.g. stereotactic cingulotomy)

EpidemiologyEpidemiology

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All AnxietyDisorders

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Kessler et al., 1995

F44 Dissociative (Conversion) F44 Dissociative (Conversion) DisordersDisorders

F44 F44 Dissociative Dissociative ((conversionconversion)) disorders disorders F44.0F44.0 Dissociative amnesia Dissociative amnesia F44.1F44.1 Dissociative fugue Dissociative fugue F44.2F44.2 Dissociative stupor Dissociative stupor F44.3F44.3 Trance and possession disorders Trance and possession disorders F44.4F44.4 Dissociative motor disorders Dissociative motor disorders F44.5F44.5 Dissociative convulsions Dissociative convulsions F44.6F44.6 Dissociative anaesthesia and sensory loss Dissociative anaesthesia and sensory loss F44.7F44.7 Mixed dissociative Mixed dissociative ((conversionconversion)) disorders disorders F44.8F44.8 Other dissociative Other dissociative ((conversionconversion)) disorders disorders F44.9F44.9 Dissociative Dissociative ((conversionconversion)) disorder, unspecified disorder, unspecified

Dissociative (Conversion) Dissociative (Conversion) DisordersDisorders

The common theme shared by dissociative disorders The common theme shared by dissociative disorders is a partial or complete loss of the normal is a partial or complete loss of the normal integration between memories of the past, integration between memories of the past, awareness of identity and immediate sensations, awareness of identity and immediate sensations, and control of bodily movements. There is normally and control of bodily movements. There is normally a considerable degree of conscious control over the a considerable degree of conscious control over the memories and sensations that can be selected for memories and sensations that can be selected for immediate attention, and the movements that are to immediate attention, and the movements that are to be carried out.be carried out.

The term “conversion hysteria” should be avoided, The term “conversion hysteria” should be avoided, because it is confusing and stigmatizing.because it is confusing and stigmatizing.

The prevalence is not exactly known (up to 10%) The prevalence is not exactly known (up to 10%) .. Sudden onset and termination of dissociative statesSudden onset and termination of dissociative states.. There are several forms of dissociative syndromes.There are several forms of dissociative syndromes.

Dissociative AmnesiaDissociative Amnesia The main feature is loss of memory, usually of The main feature is loss of memory, usually of

important recent event, which is not due to organic important recent event, which is not due to organic mental disorder and is too extensive to be mental disorder and is too extensive to be explained by ordinary forgetfulness or fatigue. explained by ordinary forgetfulness or fatigue.

The amnesia is usually centered on traumatic The amnesia is usually centered on traumatic events, such as accidents, combat experiences, or events, such as accidents, combat experiences, or unexpected bereavements, and used to be partial unexpected bereavements, and used to be partial and selective. and selective.

The amnesia typically develops suddenly and can The amnesia typically develops suddenly and can last from minutes to days. last from minutes to days.

Differential diagnosis: complicated; it is necessary Differential diagnosis: complicated; it is necessary to rule out all organic brain disorders as well as to rule out all organic brain disorders as well as various intoxications. The most difficult various intoxications. The most difficult differentiation is from conscious simulation - differentiation is from conscious simulation - malingering.malingering.

Dissociative StuporDissociative Stupor The individual suffers from diminution or absence of The individual suffers from diminution or absence of

voluntary movement and normal responsiveness to voluntary movement and normal responsiveness to external stimuli such as light, noise, and touch. external stimuli such as light, noise, and touch.

The person lies or sits largely motionless for long The person lies or sits largely motionless for long periods of time. periods of time.

Speech and spontaneous and purposeful movement Speech and spontaneous and purposeful movement are completely absent. are completely absent.

Muscle tone, posture, breathing, and sometimes Muscle tone, posture, breathing, and sometimes eye-opening and coordinated eye movements are eye-opening and coordinated eye movements are such that it is clear that the individual is neither such that it is clear that the individual is neither asleep nor unconscious. asleep nor unconscious.

Positive evidence of psychogenic causation in the Positive evidence of psychogenic causation in the form of either recent stressful events or prominent form of either recent stressful events or prominent interpersonal or social problems.interpersonal or social problems.

Trance and Possession Trance and Possession DisordersDisorders

There is a temporary loss of both the There is a temporary loss of both the sense of personal identity and full sense of personal identity and full awareness of the surroundings. The awareness of the surroundings. The individual can act as if taken over by individual can act as if taken over by another personality, spirit, deity, or another personality, spirit, deity, or “force”. Repeated sets of “force”. Repeated sets of extraordinary movements, postures, extraordinary movements, postures, and utterances can be observed.and utterances can be observed.

Dissociative Disorders of Dissociative Disorders of Movement and SensationMovement and Sensation

There is a loss of or interference with movements or loss of There is a loss of or interference with movements or loss of sensations (usually cutaneous). Mild and transient varieties of sensations (usually cutaneous). Mild and transient varieties of these disorders are often seen in adolescence, particularly in these disorders are often seen in adolescence, particularly in girls, but the chronic varieties are usually found in young adults.girls, but the chronic varieties are usually found in young adults.

Dissociative motor disordersDissociative motor disorders Dissociative convulsionsDissociative convulsions Dissociative anaesthesiaDissociative anaesthesia Ganser’s syndromeGanser’s syndrome – „– „approximate” or grossly incorrect answersapproximate” or grossly incorrect answers MMultiple personality disorderultiple personality disorder means the apparent existence of means the apparent existence of

two or more distinct personalities within an individual, with only two or more distinct personalities within an individual, with only one of them being evident at a time (Mr. Jekyl and Mr. Hyde). one of them being evident at a time (Mr. Jekyl and Mr. Hyde). Each personality is complete, with its own memories, behaviours, Each personality is complete, with its own memories, behaviours, and preferences, but neither has access to the memories of the and preferences, but neither has access to the memories of the other and the two are almost always unaware of each other’s other and the two are almost always unaware of each other’s existence. Change from one personality to another is in the first existence. Change from one personality to another is in the first instance usually sudden and closely associated with traumatic instance usually sudden and closely associated with traumatic events. events.

Clinical ManagementClinical Management

PsychotherapyPsychotherapy is a method of choice of is a method of choice of treatment of dissociative disorders treatment of dissociative disorders ((e.g. e.g. psychodynamic programspsychodynamic programs,, hypnosis hypnosis))..

Medications have no proven value with Medications have no proven value with exception of sodium amobarbital exception of sodium amobarbital interview.interview.

F43 Reaction to Severe Stress, F43 Reaction to Severe Stress, and Adjustment Disordersand Adjustment Disorders

F43F43 Reaction to severe stress, and Reaction to severe stress, and adjustment disordersadjustment disorders

F43.0F43.0 Acute stress reaction Acute stress reaction

F43.1F43.1 Post-traumatic stress disorder Post-traumatic stress disorder

F43.2F43.2 Adjustment disorders Adjustment disorders

F43.8F43.8 Other reactions to severe stress Other reactions to severe stress

F43.9F43.9 Reaction to severe stress, Reaction to severe stress, unspecified unspecified

Reaction to Severe Stress, and Reaction to Severe Stress, and Adjustment DisordersAdjustment Disorders

This category differs from others in that it includes This category differs from others in that it includes disorders identifiable not only on grounds of disorders identifiable not only on grounds of symptomatology and course but also on the basis of symptomatology and course but also on the basis of one or other of two one or other of two

Causative influences:Causative influences:• an exceptionally stressful life event (e.g. natural or man-an exceptionally stressful life event (e.g. natural or man-

made disaster, combat, serious accident, witnessing the made disaster, combat, serious accident, witnessing the violent death of others, or being the victim of torture, violent death of others, or being the victim of torture, terrorism, rape, or other crime) producing an acute stress terrorism, rape, or other crime) producing an acute stress reactionreaction

• significant life change leading to continued unpleasant significant life change leading to continued unpleasant circumstances that result in an adjustment disordercircumstances that result in an adjustment disorder

Stressful eventStressful event is thought to be the is thought to be the primary and primary and overriding causal factoroverriding causal factor, and the disorder would not , and the disorder would not have occurred without its impact.have occurred without its impact.

Acute Stress ReactionAcute Stress Reaction A transient disorder of significant severity, which develops in an A transient disorder of significant severity, which develops in an

individual without any previous mental disorder in response to individual without any previous mental disorder in response to exceptional physical and/or psychological stress. exceptional physical and/or psychological stress.

Not all people exposed to the same stressful event develop the Not all people exposed to the same stressful event develop the disorder.disorder.

The symptoms: an initial state of „daze”, with some constriction The symptoms: an initial state of „daze”, with some constriction of the field of consciousness and narrowing of attention, of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the may be followed either by further withdrawal from the surrounding situation (extreme variant - dissociative stupor), or surrounding situation (extreme variant - dissociative stupor), or by agitation and overactivity. by agitation and overactivity.

Autonomic signs - tachycardia, sweating or flushing, as well as Autonomic signs - tachycardia, sweating or flushing, as well as other anxiety or depressive symptoms. other anxiety or depressive symptoms.

The symptoms usually appear within minutes of the impact of The symptoms usually appear within minutes of the impact of the stressful event, and disappear within several hours, the stressful event, and disappear within several hours, maximally 2—3 days.maximally 2—3 days.

Post-traumatic Stress Disorder Post-traumatic Stress Disorder (PTSD)(PTSD)

PTSD is a delayed and/or protracted response to a stressful PTSD is a delayed and/or protracted response to a stressful event of an exceptionally threatening or catastrophic nature. event of an exceptionally threatening or catastrophic nature.

The three major elements of PTSD include The three major elements of PTSD include 1)1) reexperiencing the trauma through dreams or recurrent and reexperiencing the trauma through dreams or recurrent and

intrusive thoughts (“flashbacks”)intrusive thoughts (“flashbacks”)2)2) showing emotional numbing such as feeling detached from othersshowing emotional numbing such as feeling detached from others3)3) having symptoms of autonomic hyperarousal such as irritability having symptoms of autonomic hyperarousal such as irritability

and exaggerated startle response, insomniaand exaggerated startle response, insomnia Commonly there is fear and avoidance of cues that remind the Commonly there is fear and avoidance of cues that remind the

sufferer of the original trauma. Anxiety and depression are sufferer of the original trauma. Anxiety and depression are commonly associated with the above symptoms. Excessive use commonly associated with the above symptoms. Excessive use of alcohol and drugs may be a complicating factor.of alcohol and drugs may be a complicating factor.

The onset follows the trauma with a latency period, which may The onset follows the trauma with a latency period, which may range from several weeks to months, but rarely more than half range from several weeks to months, but rarely more than half a year. a year.

The lifetime prevalence is estimated at about 0.5% in men and The lifetime prevalence is estimated at about 0.5% in men and 1.2% in women.1.2% in women.

Post-traumatic Stress Disorder Post-traumatic Stress Disorder (PTSD)(PTSD)

Acute Reaction

on Trauma

Flashback

Trauma

Clinical ManagementClinical Management

PharmacologicalPharmacological approach: approach:• antidepressantantidepressant medication medication• short-term short-term benzodiazepinesbenzodiazepines trials trials• mood stabilizersmood stabilizers (carbamazepine, valproate) (carbamazepine, valproate)• antipsychoticsantipsychotics

PsychotherapyPsychotherapy is also of importance - CBT is also of importance - CBT using education and exposure techniques using education and exposure techniques

Group therapyGroup therapy, , family therapyfamily therapy and and self-self-help groupshelp groups are widely recommended. are widely recommended.

Adjustment DisordersAdjustment Disorders Adjustment disorder comprises states of subjective distress Adjustment disorder comprises states of subjective distress

and emotional disturbance arising in the period of adaptation and emotional disturbance arising in the period of adaptation to a significant life change or to the consequences of a to a significant life change or to the consequences of a stressful life event, such as serious physical illness, stressful life event, such as serious physical illness, bereavement or separation, migration or refugee status.bereavement or separation, migration or refugee status.

The clinical picture: depressed mood, anxiety, worry, a feeling The clinical picture: depressed mood, anxiety, worry, a feeling of inability to cope, plan ahead, or continue in the present of inability to cope, plan ahead, or continue in the present situation, and some degress of disability in the performance of situation, and some degress of disability in the performance of daily routine.daily routine.

Onset - within 1 month; duration - below 6 months.Onset - within 1 month; duration - below 6 months. More frequently women, unmarried and young persons. More frequently women, unmarried and young persons.

PsychotherapyPsychotherapy is the first line treatment of this disorder. is the first line treatment of this disorder. Symptomatic treatment may comprise short trial of hypnotics Symptomatic treatment may comprise short trial of hypnotics or benzodiazepines.or benzodiazepines.

F45 Somatoform DisordersF45 Somatoform Disorders

F45 F45 Somatoform disordersSomatoform disorders

F45.0F45.0 Somatization disorder Somatization disorder

F45.1F45.1 Undifferentiated somatoform disorder Undifferentiated somatoform disorder

F45.2F45.2 Hypochondriacal disorder Hypochondriacal disorder

F45.3F45.3 Somatoform autonomic dysfunction Somatoform autonomic dysfunction

F45.4F45.4 Persistent somatoform pain disorder Persistent somatoform pain disorder

F45.8F45.8 Other somatoform disorders Other somatoform disorders

F45.9F45.9 Somatoform disorder, unspecified Somatoform disorder, unspecified

F45 F45 Somatoform DisordersSomatoform Disorders Somatoform disorders Somatoform disorders -- multiple, recurrent and multiple, recurrent and

frequent somatic complaints requiring medical frequent somatic complaints requiring medical attention without association with any physical attention without association with any physical disorder are prominent. disorder are prominent.

The medical history of multiple contacts with The medical history of multiple contacts with primary care and specialized health services is primary care and specialized health services is typical before the patient is referred to typical before the patient is referred to psychiatric care.psychiatric care.

Characteristics of somatoform disordersCharacteristics of somatoform disorders::1.1. somatic complains of many medical maladies somatic complains of many medical maladies

without association with serious demonstrable without association with serious demonstrable peripheral organ disorderperipheral organ disorder

2.2. psychological problems and conflicts that are psychological problems and conflicts that are important in initiating, exacerbating and maintaining important in initiating, exacerbating and maintaining the disturbancethe disturbance

F45.0 Somatization DisorderF45.0 Somatization DisorderDiagnostic GuidelinesDiagnostic Guidelines

A definite diagnosis requires the presence of all of A definite diagnosis requires the presence of all of the following:the following:

a)a) at least 2 years of multiple and variable at least 2 years of multiple and variable physical symptoms for which no adequate physical symptoms for which no adequate physical explanation has been found,physical explanation has been found,

b)b) persistent refusal to accept the advice or persistent refusal to accept the advice or reassurance of several doctors that there is no reassurance of several doctors that there is no physical explanation for the symptoms,physical explanation for the symptoms,

c)c) some degree of impairment of social and family some degree of impairment of social and family functioning attributable to the nature of functioning attributable to the nature of symptoms and resulting behavior.symptoms and resulting behavior.

F45.0 Somatization DisorderF45.0 Somatization DisorderDifferential DiagnosisDifferential Diagnosis

Medical conditions may be confused with Medical conditions may be confused with somatoform disorder especially early in their course somatoform disorder especially early in their course (multiple sclerosis, brain tumor, (multiple sclerosis, brain tumor, hyperparathyroidism, hyperthyroidism, lupus hyperparathyroidism, hyperthyroidism, lupus erythematosus). erythematosus).

Further investigation or consultation should be Further investigation or consultation should be considered in long-term somatization disorder if considered in long-term somatization disorder if there is a shift in the emphasis or stability of the there is a shift in the emphasis or stability of the physical complaints. This change in symptoms physical complaints. This change in symptoms suggests possible development of physical disease.suggests possible development of physical disease.

Affective (depressive) and anxiety disordersAffective (depressive) and anxiety disorders accompany somatization disorders but need not be accompany somatization disorders but need not be specified separately unless they are sufficiently specified separately unless they are sufficiently marked and persistent. marked and persistent.

F45.0 Somatization DisorderF45.0 Somatization DisorderTherapy and PrognosisTherapy and Prognosis

Chronic relapsing condition starting in adolescence or even as Chronic relapsing condition starting in adolescence or even as late as the third decade of life.late as the third decade of life.

New symptoms during the emotional distress.New symptoms during the emotional distress. Typical episodes last 6 to 9 months; quiescent time of 9 to 12 Typical episodes last 6 to 9 months; quiescent time of 9 to 12

months.months. Management strategies:Management strategies:

1.1. the trusting relationship between the patient and one (if possible) the trusting relationship between the patient and one (if possible) primary care physician primary care physician

2.2. set up regularly scheduled visits every 4 or 6 weeksset up regularly scheduled visits every 4 or 6 weeks3.3. keep outpatient visits brief-perform at least a partial physical keep outpatient visits brief-perform at least a partial physical

examination during each visit directed at the organ system of examination during each visit directed at the organ system of complaintcomplaint

4.4. understand symptoms as emotional message rather than a sing of understand symptoms as emotional message rather than a sing of new disease, look for signs of disease rather than focus on new disease, look for signs of disease rather than focus on symptomsymptom

5.5. avoid diagnostic tests, laboratory evaluations and operative avoid diagnostic tests, laboratory evaluations and operative procedures unless clearly indicated procedures unless clearly indicated

6.6. set a goal to get selected somatization patients referral- ready for set a goal to get selected somatization patients referral- ready for mental health caremental health care

Group therapy (time limited, behavior oriented and structured Group therapy (time limited, behavior oriented and structured group). group).

F45.1 Undifferentiated Somatoform F45.1 Undifferentiated Somatoform DisorderDisorder

The diagnosis should be considered if the complete The diagnosis should be considered if the complete and typical clinical picture of somatization disorders and typical clinical picture of somatization disorders has not been fulfilled. has not been fulfilled.

No physical basis of the symptoms presented No physical basis of the symptoms presented remains the basis for the diagnosis.remains the basis for the diagnosis.

Differential diagnosis:Differential diagnosis:• frequently occur in major depression and schizophrenia.frequently occur in major depression and schizophrenia.• chronic history of multiple somatic complaintschronic history of multiple somatic complaints• begin before the age of 30begin before the age of 30• adjustment disorder with unexplained somatic complaints adjustment disorder with unexplained somatic complaints

should last by definition less than 6 mothsshould last by definition less than 6 moths Therapy and prognosisTherapy and prognosis::

• chronic and relapsing but some cases experience only one episodechronic and relapsing but some cases experience only one episode• treatment approaches – as in somatization disordertreatment approaches – as in somatization disorder

F45.2 Hypochondriacal DisorderF45.2 Hypochondriacal Disorder

The disorder is characterized by a persistent The disorder is characterized by a persistent preoccupation and a fear of developing or having preoccupation and a fear of developing or having one or more serious and progressive physical one or more serious and progressive physical disorders.disorders.

Patients persistently complain of physical problems Patients persistently complain of physical problems or are persistently preoccupied with their physical or are persistently preoccupied with their physical appearance. appearance.

The fear is based on the misinterpretation of The fear is based on the misinterpretation of physical signs and sensations.physical signs and sensations.

Physician physical examination does not reveal any Physician physical examination does not reveal any physical disorder, but the fear and convictions physical disorder, but the fear and convictions persist despite the reassurance.persist despite the reassurance.

F45.2 Hypochondriacal DisorderF45.2 Hypochondriacal DisorderDiagnostic GuidelinesDiagnostic Guidelines

Presence of both of the following criteria:Presence of both of the following criteria:1.1.persistent belief in the presence of at least one serious persistent belief in the presence of at least one serious

physical illness underlying the presenting symptom or physical illness underlying the presenting symptom or symptoms, even thought repeated investigations and symptoms, even thought repeated investigations and examinations have not identified any adequate physical examinations have not identified any adequate physical explanation, or a persistent preoccupation with presumed explanation, or a persistent preoccupation with presumed deformity or disfigurementdeformity or disfigurement

2.2.persistent refusal to accept the advice and reassurance of persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or several different doctors that there is no physical illness or abnormity underlying the symptomsabnormity underlying the symptoms

Includes: Body dysmorphic disorder, Includes: Body dysmorphic disorder, Dysmorphophobia (non delusional), Dysmorphophobia (non delusional), Hypochondriacal neurosis, Hypochondriasis, Hypochondriacal neurosis, Hypochondriasis, NosophobiaNosophobia

F45.2 Hypochondriacal DisorderF45.2 Hypochondriacal Disorder Differential DiagnosisDifferential Diagnosis

Basic - ruling out underlying organic disease.Basic - ruling out underlying organic disease. The main somatoform disorder that need to be The main somatoform disorder that need to be

differentiated from hypochondriasis is differentiated from hypochondriasis is somatization disorder.somatization disorder.

Hypochondriasis needs to be distinguished from Hypochondriasis needs to be distinguished from factitious disorder with predominantly physical factitious disorder with predominantly physical signs and from malingering.signs and from malingering.

F45.2 Hypochondriacal DisorderF45.2 Hypochondriacal Disorder Therapy and PrognosisTherapy and Prognosis

The illness is usually long-standing, with episodes The illness is usually long-standing, with episodes lasting months or years. Recurrences occur lasting months or years. Recurrences occur frequently after psychosocial distress.frequently after psychosocial distress.

Higher socio-economic status, presence of other Higher socio-economic status, presence of other treatable condition, anxiety and depression, an treatable condition, anxiety and depression, an acute onset, absence of personality disorder or acute onset, absence of personality disorder or comorbid organic disease predict better outcome.comorbid organic disease predict better outcome.

NNo evidence-based treatment has been described. o evidence-based treatment has been described. Patients strongly refuse the mental health care Patients strongly refuse the mental health care

professionals and remain in primary health care.professionals and remain in primary health care. Similar management and group therapy strategy as Similar management and group therapy strategy as

in somatization disorder may be useful.in somatization disorder may be useful.

F45.3 Somatoform Autonomic F45.3 Somatoform Autonomic DysfunctionDysfunction

The symptoms are presented as physical disorder of The symptoms are presented as physical disorder of system or organ largely or completely under system or organ largely or completely under controlled by autonomic innervation, i.e. the controlled by autonomic innervation, i.e. the cardiovascular, gastrointestinal, or respiratory cardiovascular, gastrointestinal, or respiratory system and some aspects of genitourinary system. system and some aspects of genitourinary system.

The symptoms are usually of two typesThe symptoms are usually of two types::1.1. complaints based on objective signs of autonomic arousal complaints based on objective signs of autonomic arousal

(palpitation, sweating, flushing, tremor)(palpitation, sweating, flushing, tremor)

2.2. idiosyncratic, subjective, non-specific (fleeting aches and idiosyncratic, subjective, non-specific (fleeting aches and pains, burning, heaviness, tightness, sensation of being pains, burning, heaviness, tightness, sensation of being bloated or distended)bloated or distended)

These symptoms patients refer to a specific organ or These symptoms patients refer to a specific organ or system. system.

In many cases there is evidence of psychological In many cases there is evidence of psychological stress or current problems related to the disorder.stress or current problems related to the disorder.

F45.3 Somatoform Autonomic DysfunctionF45.3 Somatoform Autonomic Dysfunction Diagnostic GuidelinesDiagnostic Guidelines

a)a) Symptoms of autonomic arousal such as Symptoms of autonomic arousal such as palpitations, sweating, tremor, flushing which are palpitations, sweating, tremor, flushing which are troublesome and persistenttroublesome and persistent

b)b) Additional subjective symptoms referred to Additional subjective symptoms referred to specific organ or systemspecific organ or system

c)c) Preoccupation with the symptoms and possibility Preoccupation with the symptoms and possibility of serious (often non specified disorder). It does of serious (often non specified disorder). It does not respond to repeated explanations and not respond to repeated explanations and reassurance of physiciansreassurance of physicians

d)d) No evidence of a significant disturbance of No evidence of a significant disturbance of structure or function of the system or organstructure or function of the system or organ

F45.3 Somatoform Autonomic DysfunctionF45.3 Somatoform Autonomic Dysfunction Differential DiagnosisDifferential Diagnosis

In comparison with generalized anxiety there is In comparison with generalized anxiety there is predominance of psychological component of predominance of psychological component of autonomic arousal. In somatization disorders autonomic arousal. In somatization disorders autonomic symptoms when they are present they autonomic symptoms when they are present they are nor prominent nor persistent and symptoms are nor prominent nor persistent and symptoms are not so persistently attributed to one organ or are not so persistently attributed to one organ or system.system.

Excludes: psychological and behavioural factors Excludes: psychological and behavioural factors associated with disorders or diseases classified associated with disorders or diseases classified elsewhere (F54).elsewhere (F54).

The individual disorder may be classified by fifth The individual disorder may be classified by fifth character indicating the organ or system affectedcharacter indicating the organ or system affected

F45.3 Somatoform Autonomic DysfunctionF45.3 Somatoform Autonomic Dysfunction Therapy and PrognosisTherapy and Prognosis

Similar chronic relapsing condition as the Similar chronic relapsing condition as the somatization disorder. somatization disorder.

Patients report worse health than do those with Patients report worse health than do those with chronic medical condition and their report of chronic medical condition and their report of specific symptoms if they meet the severity specific symptoms if they meet the severity criteria is sufficient and need not to be considered criteria is sufficient and need not to be considered legitimate by the clinician.legitimate by the clinician.

Treatment strategies will be similar stressing the Treatment strategies will be similar stressing the importance of the interdisciplinary collaboration.importance of the interdisciplinary collaboration.

F45.4 Persistent Somatoform F45.4 Persistent Somatoform Pain DisorderPain Disorder

The predominant symptom is a persistent severe The predominant symptom is a persistent severe and distressing pain that cannot be explained and distressing pain that cannot be explained fully by a physiological process of physical illness.fully by a physiological process of physical illness.

Pain occurs in association with emotional conflicts Pain occurs in association with emotional conflicts or psychosocial problems. or psychosocial problems.

The expression of chronic pain may vary with The expression of chronic pain may vary with different personalities and cultures.different personalities and cultures.

TThe patient is not malingering and the complaints he patient is not malingering and the complaints about the intensity of the pain are to be believed.about the intensity of the pain are to be believed.

F45.4 Persistent Somatoform PainF45.4 Persistent Somatoform Pain Diagnostic GuidelinesDiagnostic Guidelines

The clinical examination should focus onThe clinical examination should focus ona)a) the extend the patient is disabled by the painthe extend the patient is disabled by the pain

b)b) the degree of complicating emotional factors and the degree of complicating emotional factors and comorbid psychiatric conditionscomorbid psychiatric conditions

Includes: psychalgia, psychogenic backache or Includes: psychalgia, psychogenic backache or headache, somatoform pain disorder.headache, somatoform pain disorder.

F45.4 Persistent Somatoform PainF45.4 Persistent Somatoform PainDifferential DiagnosisDifferential Diagnosis

Not included:Not included:• pain presumed to be of psychological origin occurring pain presumed to be of psychological origin occurring

during the course of depression or schizophreniaduring the course of depression or schizophrenia• pain due to known or inferred physiological mechanism pain due to known or inferred physiological mechanism

such as muscle tension pain or migraine but still such as muscle tension pain or migraine but still believed to have psychological cause are coded as P54believed to have psychological cause are coded as P54

• the somatoform pain disorder has to be differentiated the somatoform pain disorder has to be differentiated from histrionic behaviour in reaction to organic painfrom histrionic behaviour in reaction to organic pain

Excluded backache NOS (M54.9), pain NOS Excluded backache NOS (M54.9), pain NOS (acute, chronic) (R52.-), tension type headache (acute, chronic) (R52.-), tension type headache (G44.2).(G44.2).

F45.4 Persistent Somatoform PainF45.4 Persistent Somatoform PainTherapy and prognosisTherapy and prognosis

Once diagnosis is completed the outpatient Once diagnosis is completed the outpatient treatment on regular basis by one interested treatment on regular basis by one interested physician has to be carried out. physician has to be carried out.

Patients have to be reassured that the treatment Patients have to be reassured that the treatment continues if there is some improvement.continues if there is some improvement.

Those with painThose with pain--prone reaction to distress are prone reaction to distress are described to have poor or transient improvement. described to have poor or transient improvement.

Patients with comorbid depression may improve Patients with comorbid depression may improve with antidepressant medication. with antidepressant medication.

Treatment with any type of the pain disorder Treatment with any type of the pain disorder subtypes needs to be multidisciplinary and subtypes needs to be multidisciplinary and multidimensional from the onset.multidimensional from the onset.

F45.8 Other Somatoform DisordersF45.8 Other Somatoform Disorders In these disorders the presented complaints are not mediated In these disorders the presented complaints are not mediated

through the autonomic nervous, and are limited to specific through the autonomic nervous, and are limited to specific system of body part. system of body part.

Any other disorders of sensation not due to physical disorders Any other disorders of sensation not due to physical disorders which are closely associated in time with stressful event or which are closely associated in time with stressful event or problem and which results in significant increase of attention for problem and which results in significant increase of attention for the patient, personal or medical care should also be classified the patient, personal or medical care should also be classified here. here.

Swelling, movement on the skin and paraesthesias (tingling Swelling, movement on the skin and paraesthesias (tingling or/and numbness) are common. or/and numbness) are common.

Disorders included in this category:Disorders included in this category:a)a) ““globus hystericusglobus hystericus

b)b) psychogenic torticollis and other disorders of spasmodic psychogenic torticollis and other disorders of spasmodic movement (excluding Tourette’s syndrome)movement (excluding Tourette’s syndrome)

c)c) psychogenic pruritus but excluding specific skin lesions such as psychogenic pruritus but excluding specific skin lesions such as alopecia, dermatitis eczema, or urticaria of psychogenic originalopecia, dermatitis eczema, or urticaria of psychogenic origin

F45.9 Somatoform Disorder, F45.9 Somatoform Disorder, UnspecifiedUnspecified

Includes unspecified physiological or Includes unspecified physiological or psychosomatic disorder in patients whose psychosomatic disorder in patients whose symptoms and associated disability do not symptoms and associated disability do not fit the full criteria for other somatoform fit the full criteria for other somatoform disorders. The treatment and the outcome disorders. The treatment and the outcome however do not considerably differ.however do not considerably differ.

Other Neurotic DisordersOther Neurotic Disorders

F48F48 Other neurotic disorders Other neurotic disorders

F48.0F48.0 Neurasthenia Neurasthenia

F48.1F48.1 Depersonalization-derealization Depersonalization-derealization syndrome syndrome

F48.8F48.8 Other specified neurotic disorders Other specified neurotic disorders

F48.9F48.9 Neurotic disorder, unspecified Neurotic disorder, unspecified