Neurotic Disorders and Somatisation

7/31/2019 Neurotic Disorders and Somatisation

1/26

7/31/2019 Neurotic Disorders and Somatisation

2/26

Introduction

Neurotic disorders are a collection of psychiatric disorderswithout psychotic symptoms and lacking the intensepsychopathology of, say, hypomania or major depression.Having said this, neurotic disorders are a major source ofsuffering to individuals, their families and to society. The costof treating alll neurotic disorders would be substantial, but the

cost of non-treatment to society (in terms of lost productionand lost efficiency) is probably greater. According to Croft-Jeffreys & Wilkinson (1989) the estimated cost to the UK ofneurotic illness in 1985 was 373,000,000. A decade later thesum must exceed half a billion pounds a year. After all, over athird of sickness certificates are for psychiatric illness, much ofthis being neurotic, (Jenkins, 1985). The persistent nature ofanxiety disorder over time ,with its childhood antecedents andoften recurrent prognosis, means that it may dominatesufferer's lives, (Angst & Vollrath, 1991). Only chronic heartdisease produces more disability.

7/31/2019 Neurotic Disorders and Somatisation

3/26

Neurosis(from the Greek ) refers to aclass of functional mental disorder involvingdistress but not delusions nor hallucinations, wherebehavior is not outside socially acceptable

norms.[1] It is also known as psychoneurosis orneurotic disorder, and thus those suffering from itare said to be neurotic.

Once a common psychiatric diagnosis, the term isno longer part of mainstream psychiatricterminology in the United States, though itcontinues to be employed in psychoanalytic theoryand practice, and in various other theoreticaldisciplines.

7/31/2019 Neurotic Disorders and Somatisation

4/26

History and use of the term

Neurosiswas coined by the Scottish doctor William Cullen in 1769to refer to "disorders of sense and motion" caused by a "generalaffection of the nervous system." For him, it described variousnervous disorders and symptoms that could not be explainedphysiologically. It derives from the Greek word neuron(nerve) withthe suffix -osis(diseased or abnormal condition). The term was

however most influentially defined by Carl Jung and Sigmund Freudover a century later. It has continued to be used in contemporarytheoretical writing in psychology and philosophy.[2]

The American Diagnostic and Statistical Manual of Mental Disorders(DSM) has eliminated the category of Neurosis, reflecting a decisionby the editors to provide descriptions of behavior as opposed to

hidden psychological mechanisms as diagnostic criteria.[3], and,according to The American Heritage Medical Dictionary, it is "nolonger used in psychiatric diagnosis."[4] These changes to the DSMhave been highly controversial.[5]

7/31/2019 Neurotic Disorders and Somatisation

5/26

Generalised anxiety disorder

Panic disorder

Phobias - specific and generalised

Obsessive compulsive disorder

Dissociation disorder

Somatisation disorders

Adjustment disorders

Post-traumatic disorder

7/31/2019 Neurotic Disorders and Somatisation

6/26

Psychoanalytical account ofneurosis

As an illness, neurosis represents a variety of mental disorders in whichemotional distress or unconscious conflict is expressed through variousphysical, physiological, and mental disturbances, which may includephysical symptoms (e.g., hysteria). The definitive symptom is anxieties.Neurotic tendencies are common and may manifest themselves asdepression, acute or chronic anxiety, obsessive-compulsive tendencies,

phobias, and even personality disorders, such as borderline personalitydisorder or obsessive-compulsive personality disorder. It has perhaps beenmost simply defined as a "poor ability to adapt to one's environment, aninability to change one's life patterns, and the inability to develop a richer,more complex, more satisfying personality."[6] Neurosis should not bemistaken for psychosis, which refers to loss of touch with reality, orneuroticism, a fun

damental personality trait according to psychologicaltheory.

According to psychoanalytic theory, neuroses may be rooted in ego defensemechanisms, but the two concepts are not synonymous. Defensemechanisms are a normal way of developing and maintainin

g a consistentsense of self (i.e., an ego), while only those thought and behavior patternsthat produce difficulties in living should be termed neuroses.

7/31/2019 Neurotic Disorders and Somatisation

7/26

Jung's theory of neurosis

Main article: Jung's theory of neurosis Jung found his approach particularly fitting for people who are successfully adjusted

by normal social standards, but who nevertheless have issues with the meaning oftheir life.

I have frequently seen people become neurotic when they content themselves withinadequate or wrong answers to the questions of life (Jung, [1961] 1989:140).

The majority of my patients consisted not of believers but of those who had lost their

faith (Jung, [1961] 1989:140). [Contemporary man] is blind to the fact that, with all his rationality and efficiency, he

is possessed by "powers" that are beyond his control. His gods and demons have notdisappeared at all; they have merely got new names. They keep him on the run withrestlessness, vague apprehensions, psychological complications, an insatiable needfor pills, alcohol, tobacco, food and, above all, a large array of neuroses. (Jung,1964:82).

Jung found that the unconscious finds expression primarily through an individualsinferior psychological function, whether it is thinking, feeling, sensing, or intuition. Thecharacteristic effects of a neurosis on the dominant and inferior functions arediscussed in Psychological Types.

Jung saw collective neuroses in politics: "Our world is, so to speak, dissociated like aneurotic

7/31/2019 Neurotic Disorders and Somatisation

8/26

Effects and symptoms

There are many different specific forms of neurosis: pyromania,obsessive-compulsive disorder, anxiety neurosis, hysteria (in whichanxiety may be discharged through a physical symptom), and anendless variety of phobias. According to Dr. George Boeree, effectsof neurosis can involve:

...anxiety, sadness or depression, anger, irritability, mentalconfusion, low sense of self-worth, etc., behavioral symptoms suchas phobic avoidance, vigilance, impulsive and compulsive acts,lethargy, etc., cognitive problems such as unpleasant or disturbingthoughts, repetition of thoughts and obsession, habitual fantasizing,negativity and cynicism, etc. Interpersonally, neurosis involvesdependency, aggressiveness, perfectionism, schizoid isolation,

socio-culturally inappropriate behaviors

7/31/2019 Neurotic Disorders and Somatisation

9/26

Generalised Anxiety Disorder(GAD)

GAD may affect up to 5% of the general population.The classical syndrome of generalised anxietydisorder involves both psychological and somaticsymptoms (Rapee, 1991). Psychological symptoms

include free-floating anxiety (ie anxiety not attachedto any particular object or event) and a fearfulpreoccupation with the future. (Tiller, 1994). Evenso, in the quest to alleviate anxiety disorders,doctors should be careful not to rely purely on drugs

or psychological treatment. As Tiller comments,'doctors should avoid stigmatising people withmental illness by implying that everybody should beable to overcome mental distress without the needfor drugs'.

7/31/2019 Neurotic Disorders and Somatisation

10/26

Somatic symptoms include tachycardia,palpitations, essential tremor, musculartension, hypertension, dizziness, sweating,

hyperventilation, and epigastric discomfort.Anxiety is often a presenting symptom ofdepressive illness, and it is sometimes

difficult to disentangle the two.

7/31/2019 Neurotic Disorders and Somatisation

11/26

Brief counselling and training in problem-solving techniquesto help patients with GAD without resorting to anxiolytics and

apparently without increasing demands on precious GP time(Catalan et al, 1984 & Andrews, 1991).

Self-help programmes for anxiety disorder using anxiety managementbooklets have been found effective, (Sorby, Reavley, & Huber,1991).

General practitioners welcome clinical psychologists' help in themanagement of anxiety disorders, and desire an increasedavailability of clinical psychology services, (Deans and Skinner,1992).

Useful drug treatments for anxiety include short courses ofbenzodiazepines, and antidepressants such as paroxetine.

Efforts have been made to reduce the use of benzodiazepines ingeneral practice, and these have been successful,

7/31/2019 Neurotic Disorders and Somatisation

12/26

7/31/2019 Neurotic Disorders and Somatisation

13/26

Panic disorder

Anxiety is felt in separate recurrent bouts (panic attacks) in whichsomatic symptoms of palpitations and dizziness may predominate.Sufferers often feel that they are about to die during an attack.

Depersonalisation and derealisation may accompany the attack. The sufferer tends to avoid the places where such attacks have

occurred in the past. Thus a series of panic attacks may precipitateagoraphobia. Sometimes sufferers overcome their fear by mis-usingalcohol or benzodiazepines.

Organic causes for anxiety and panic disorders must be excluded.Thyrotoxicosis often presents with anxiety. Mitral valve prolapse andcardiac arrhythmias are also associated.

Cognitive therapy has been shown to be of benefit (Beck et al, 1992)in addition to the psychological and drug treatments outlined abovefor GAD.

7/31/2019 Neurotic Disorders and Somatisation

14/26

Phobias

Defined as an excessive and somewhat irrational fear of someobject or situation which is usually so disturbing that it leads toavoidance of that object or situation (avoidance behaviour). Avoidingthe feared thing only makes further contact with it even moreanxiety-provoking. About 8% of the general public have some kindof phobia.

Most people have fears of specific things like a fear of the dark orspiders, but rarely do these fears dominate their lives. When thefears become preoccupying and the individual takes special steps toavoid the feared thing (like a mother asking her son to read throughall her magazines first to ensure that there are no pictures ofspiders) then a minor fear becomes a specific phobia.

Ninety per cent of sufferers are women. Psychological treatment is based on two principles: reducing the

anxiety associated with the feared object and practising exposure tothe feared object or situation.

7/31/2019 Neurotic Disorders and Somatisation

15/26

Agoraphobia

A fear of the market place, of crowds, of travelling onpublic transport, and an avoidance of social situationsand a marked tendency to stay at home, rarely, if ever,venturing outside. Three quarters of sufferers arewomen.

Behavioural therapy can be very successful, based onexposing the patient to a graded hierarchy of situationsranging say, from a walk of ten yards away from the frontdoor to a day out in town. Often the patient's partner canbe enrolled as a co-therapist. Antidepressants, including

MAOIs, may be particularly useful. Some patients mayreluctant to give up their illness behaviour, becausethere may be considerable psychological rewardsattached to it eg making the partner more attentive.

7/31/2019 Neurotic Disorders and Somatisation

16/26

Social phobias

These involve the fear of meeting people, or thefear of behaving in an out of the ordinary way incompany. Whereas the agoraphobic isfrightened of people in the mass, the social

phobic is also often afraid of one-to-oneinteractions with others. Alcohol orbenzodiazepines are often abused to reduceanxiety ahead of the event. Anticipatory anxietyimpairs performance in the feared situation

leading to a cycle of reduced confidence andincreased anxiety before the next meeting andso on.

Ob i l i di d

7/31/2019 Neurotic Disorders and Somatisation

17/26

Obsessive-compulsive disorder(OCD)

Obsessional ideas are thoughts that come repeatedly into aperson's mind, and which have some undesirable quality fas far asthat person is concerned. The ideas may be nonsensical, say, orviolent or obscene; such as ideas about harming a baby in a newmother or swear words repeatedly coming into the mind of a priest.Obsessional ideas are sometimes called intrusive thoughts.

Patients may describe intrusive thoughts as being like aconversation in their head. The key points to distinguish theseintrusive thoughts from hallucinatory voices are that they:

lack the real quality of a voice are experienced inside the sufferer's head (i.e. not experienced in

external space)

are recognised as a product of the sufferer's own mind. The intrusive thoughts are not delusional either because although

the thoughts are often incorrect the patient may volunteer howabsurd the thoughts are. In other words they have insight into thenonsensical nature of the ideas.

7/31/2019 Neurotic Disorders and Somatisation

18/26

Compulsive acts or rituals may be performed to reduce the anxietyassociated with obsessional thoughts. For example the person whocontinually fears contamination may wash and re-wash their hands manytimes a day, even to the point of breaking the skin down. Compulsive actsand rituals are sometimes perfomed to ward off some undesirable event.

Performance of these rituals may interfere with everyday life. A patient whorepeatedly spends two hours washing and showering after a toilet break atwork may lose their job.

As with other neurotic disorders there is an overlap with depressive illness(since depressive illness may have obsessional features).

Obsessional personalities are essentially meticulous and perfectionisticworkers who, if given a deadline will work to it, but who may expend greateffort in getting things just right. Their attention to detail may infuriate those

around them. In terms of treatment at least 50% of patients with OCD can be treatedusing drugs such as fluoxetine and clomipramine. In patients who canaccept it behavioural treatment with exposure and response prevention hasa high success rate.

7/31/2019 Neurotic Disorders and Somatisation

19/26

Dissociation disorders

Imagine the mind has many layers of awareness. In clearconsciousness we are aware of our surroundings and our innerthoughts usually at all levels. A thought which occurs at one level isusually apparent throughout the system. The sensation of hunger atone level is accompanied by fantasies of food and plans of how toget that food at other levels. At other levels of the mind memories of

past meals and events might be triggered too. Somehow thethoughts, memories and sensations on all these levels areintegrated.

In dissociation disorders we might imagine that somehow the layersare not being integrated properly, so that there are discrepancies ordissociations between the thought activity at different levels. Some

people speak of a 'splitting of the stream of consciousness'. Anexample of this dissociation might be that some memories arestrikingly unavailable to the conscious individual. Hypnotic or trance-like states, and depersonalisation episodes are other examples ofdissociation

7/31/2019 Neurotic Disorders and Somatisation

20/26

When something extremely unpleasant happens dissociation maybe a way of coping. Children who are being abused often feel as ifthe abuse is not happening to them, but to somebody else. They feelremoved from it all. When the abuse is not happening it may bedifficult for them to access the memories and feelings they hadwhilst they were being abused. Sometimes these split-off memories

may only be acknowledged by an abused individual years later. Theinformation about the unpleasant event is not lost, but is stored atsome relatively inaccessible level to protect the sufferer from hurt. Afurther example of dissociation is the phenomenon in battle where asoldier running across a battlefield is shot at, but continues runningoblivious of the bullet that has entered him. Only when he returns tosafety can he begin to feel the pain and acknowledge the wound hehas sustained.

7/31/2019 Neurotic Disorders and Somatisation

21/26

The lack of integration caused by dissociation may produce anumber of related disorders. Sigmund Freud described a variety ofcases, then diagnosed as hysteria, but which now attract thediagnosis of dissociative conversion disorders. An example might bea young patient who has no physical abnormality, but who isadamant that they are unable to walk. The patient may undergo

many diagnostic tests, but no abnormality is found. Other patientsmay present with atypical pains that defy our knowledge of humananatomy. Catharsis, an emotional return to the original traumaticevent, via psychotherapy, hypnosis, or drug abreaction (provoked byintravenous diazepam, say), may release the patient from theirsymptom. Often the symptoms have some symbolic meaning, sothat a child who is frightened to speak out against the abuser maydevelop an aphonia (an inability to speak), i.e. the trauma is'converted', hence the term conversion disorder.

7/31/2019 Neurotic Disorders and Somatisation

22/26

Somatisation disorder

Not all patients have the ability to formulate psychological distress inpsychological or emotional terms. They may present their innerconflicts an distress as physical symptoms. At a basic level this maybe 'a way in' to discussing their problems with their doctor, but atanother level the patient may be quite unable to accept apsychological basis for their illness at all.

In somatization disorder a patient may take their somatic symptomsfrom doctor to doctor in a vain attempt to find some test,investigation or cure that has not been offered elsewhere. Manynegative investigations and therapies may have been tried by pastdoctors to no avail. Symptoms may involve any bodily system andmay include gastric pain, belching, vomiting, nausea, itching,

burning, tingling, numbness and fatigue amidst others.

7/31/2019 Neurotic Disorders and Somatisation

23/26

The psychological factors in the presentation of somatic symptomsare apparently often underestimated by primary-care doctors (andvice-versa for psychiatrists), but an 8-week teaching packageinvolving a re-attribution model for symptoms, and using small grouptechniques, role play and video training has been shown to improverecognition and management skills (Kaaya et al, 1992 & Gask et al,

1989 ). The re-attribution model seeks to move away from adialogue about physical causes for physical symptoms, and whilstacknowledging the reality of the symptoms, looks at thepsychological factors that make them better or worse. Four stageshave been identified (Goldberg et al, 1994):

Provide clear information about negative physical examinations and

investigations whilst acknowledging the reality of the physicalsymptoms State the relevant mood state and associated symptoms and refer to

psychosocial factors previously identified Explain the relationship of mood and pain/physical symptoms

7/31/2019 Neurotic Disorders and Somatisation

24/26

Post-traumatic stress disorder

After being involved in or witnessing severe life-threatening accidents ortraumas, victims may suffer with a post-traumatic stress disorder, (PTSD).PTSD is common in soldiers and it has been described in various wars.During the first world war it was known as 'shell shock'. Symptoms of PTSDinclude episodes of re-living the trauma. Re-living may occur in flashbacksequences during the daytime or as vivid recurrent dreams during sleep.Other symptoms include hyperarousal, insomnia, social withdrawal,

numbness, fear and avoidance of cues that trigger memories of the event.Re-living the trauma may be associated with anxiety, fear and aggression.

Depression may co-exist with PTSD. Patients may also self-medicate withalcohol and substance abuse problems are often associated with thedisorder. Antidepressant therapy may be helpful. Counselling as a matter ofcourse is often offered to victims of disasters and those who witness them(e.g. stadium fires, crowd disasters). Repeated rehearsal of the trauma in

continuing therapy may not be helpful and there is evidence to show thatpsychological debriefing after traumatic experiences does not preventsubsequent psychiatric morbidity, although such debriefing may initially bevalued by the survivor, (Deahl et al, 1994)

Prognosis

7/31/2019 Neurotic Disorders and Somatisation

25/26

References

Andrews, G. (1991) The management of anxiety. Australian Prescriber, 14, 17-19. Angst, J, & Vollrath, M. (1991) The natural history of anxiety disorder. Acta

Psychiatrica Scandinavica, 84, 446-452. Bass, C. & Benjamin S. (1993) The management of chronic somatisation. British

Journal of Psychiatry, 162, 472-180.

Beck, A T, Sokol, L, Clark, D A, Berchick, R, Wright F. (1992) A crossover study offocused cognitive therapy for panic disorder. Am. J. Psychiatry, 149, 779-783.

Catalan, J, Gath, D, Edmonds, G, Ennis, J. (1984) The effects of non-prescribing ofanxiolytics in general practice: 1. Controlled evaluation of psychiatric and socialoutcome. Br. J. Psychiatry, 144, 593-602.

Craig, TK J, Drake, H, Mills, K, Boardman, AP. (1994) The South Londonsomatisation study. II Influence of stressful life events and secondary gain. BJPsych,

165, 248-258. Croft-Jeffreys, C, Wilkinson, G. (1989) Estimated costs of neurotic disorder in UKgeneral practice. Psychological Medicine, 19, 549-558.

Deahl, M P, Gillham, AB, Thomas, J, Searle,M M, & Srinivasan, M. (1994)Psychological sequelae following the Gulf War. British Journal of Psychiatry, 165, 60-65.

7/31/2019 Neurotic Disorders and Somatisation

26/26

Personality Disorders The DSM-IV defines a personality disorder as "an enduring pattern ofinner experience and behavior that deviates markedly from the expectations of the individualsculture, is pervasive, and inflexible, has an onset in adolescence or early adulthood, is stable overtime, and leads to distress or impairment". The manual identifies and describes diagnostic criteriafor 10 specific personality disorders. These are listed as below: Paranoid Personality Disorder:characterized by a pervasive pattern of distrust and suspiciousness.

Schizoid Personality Disorder: characterized by a pervasive pattern of detachment from socialrelationship

Schizotypal Personality Disorder: characterized by a pervasive pattern of acute discomfort inclose relationships, cognitive and perceptual distortions and eccentricities of behavior

Antisocial Personality Disorder: characterized by a pervasive pattern of disregard for and violationof the rights of others.

Borderline Personality Disorder: characterized by a pervasive pattern of instability in interpersonal

relationships, self-image, and affects and marked impulsivity.

Histrionic Personality Disorder: characterized by a pervasive pattern of excessive emotionality andattention seeking.

Narcissistic Personality Disorder: characterized by a pervasive pattern of grandiosity, need foradmiration and lack of empathy.

Avoidant Personality Disorder: characterized by a pervasive pattern of social inhibition, feeling of

inadequacy, and hypersensitivity to negative evaluation.Dependent Personality Disorder: characterized by a pervasive pattern of submissive and clingybehavior related to an excessive need to be taken care of.

Obsessive Compulsive Personality Disorder: characterized by a pervasive pattern ofpreoccupation with orderliness, perfectionism, and control.