Neurotic Disorders MRCPsych II, GA Module Dr. Naresh K. Buttan M.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec12 (2) Approved Consultant Psychiatrist-

Neurotic DisordersMRCPsych II, GA Module

Dr. Naresh K. ButtanM.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec12 (2) Approved

Consultant Psychiatrist- HTT & Glenbourne; PCH-CICHon’ Fellow- PCMD, Plymouth Locality Psychiatry Lead & AT-PMSTPD- CT, Health Education-South West

E-mail: [email protected], [email protected]

Neurotic Disorders- Scene Setting RCPsych ILOs 1, 2: Identify, diagnose & formulate 3, 4, 5: Investigate, Manage & Refer

• Concept- Evolution of neurosis/ anxiety• Epidemiology, C/F, Diag. Criteria, D/D• Aetiology & Management Principles• 3 case studies- 4 groups, 3 minutes on each case,

correct answer- 10 points, wrong – 0• 2 scorers, 4 major mental disorders• MCQs- Shout 1st & 10 for right & - 5 for wrong

Neurosis/Anxiety- Concept

Neurosis/ Anxiety ?• Worry (N, Webster/ Oxford Dictionary)• Stress• Normal vs. abnormal• State vs. trait• Episodic vs. Pervasive• Situational vs. Generalized• Internal (Active) vs. Reactive

Anxiety (Neurotic) Disorders: Relevance• Prevalence: General Population

• ‘Symptoms- common in gen. population• High Comorbidities• May present with physical symptoms• Proper recognition for appropriate treatment• Management- combined approach

Disorder Prev. 6/12 Rates % Lifetime Rates %

Schizophrenia 0.9 1.5

Affective Dis. 5.8 8.3

D & A dis 6.0 16.4

Anxiety Dis 8.9 14.6

Anxiety (Neurosis)- History• Greek: 3 Humors• Dark age: spirits/ divine punishments• ‘Hysteria’ – Hippocrates (15th-16th Cent.)• ‘Neurosis’- William Cullen (1777)• ‘Studies in Hysteria’- S. Freud (1895)• Psychoanalytical - repression, topological mind,

fixations, defense mechanisms• WW I → ‘Emotional’ vs. ‘Physical’, ‘Conversion

Hysteria’ or ‘Phobic Neurosis’

Anxiety (Neurosis)- History…..• ‘Emergency Reaction’- Waltor Canon (1920s)- ‘Fight

or Flight’ response via ANS • “Conditioning’- John Watson (1930s)- traumatic

learning situations• ‘Instrumental Conditioning’- Mowrer (1940s)-

‘reinforcers’ & ‘desensitization’• Canon Bard Theory (HPA axis)• Tranquilizers- Benzos, Antidepressants• Imaging: Frontal cortex & B/L Caudate in OCD,

Temporal lobes- Panic →TLEs

Anxiety (Neuroses)- Present• Early Adverse

Life Experiences.

• Genetic Predisposition

Bio. Vulnerabilty Personality/ Temperament

Traumas/ SLEs

D & A

Physical Illnesses

Bio. Changes in Brain Fn.

Anxiety symptoms

Natural/ Environmental

Blood/ Injury/ Injection

Animal

Other

Anxiety Disorders

GAD Panic Phobic PTSD OCD

Simple/ Sp. Compd./Gen.

Agoraphobia Social Phobia

Case 1• 35 YO single female, working as receptionist,

presents with 12/12 h/o of vague body aches, headaches, wt loss, initial insomnia, worried about anything & everything, lethargy, no sadness, cold sweats, numbness, using alcohol as coping.

• No past/family history of mental illness• Personal History: Uneventful birth, early

development, schooling.• Lost 3 sibs in RTA during her college days

Case 1….

• Parents elderly in care home• Previous relationship ended 18/12 ago due to her

own worries & frequent arguments • Job cuts in work place, thinks she may lose her job

despite frequent reassurances from boss• No D&A issues, GPE- NAD, ↑sed HR• MSE: Tense, edgy, tremors, sweaty, ‘fear of dying’, no

delusions/ hallucinations/suicidal thoughts, MMSE-27/30-recall*

Case 1…

• Gp 1: Diagnoses/ differentials

• Gp 2: Aetiology

• Gp 3: Treatments

• Gp 4: Risks/prognosis

Generalised Anxiety Disorder• Essence: generalised free floating persistent anxiety• Epidemiology: 6/12- ECA: 2.5- 6.4%, Early onset (Av 21),

F>M, Single, Unemployed.

• Aetiology: a) Genetic: Heritability 30%b) Neurobiological: ANS arousal, loss of regulatory control

of cortisol (HPA axis), abnormal neurotransmitters (↓GABA, 5HT dysregulation,)

c) Psychological: Unexpected -ve SLEs (death, loss, rape), chronic stressors; conditioning, reinforcers, failed repression, loss of object /attachment

Generalised Anxiety Disorder….Diagnostic criteria: ICD 10-: Pervasive anxiety & at least 4

(min 1 from autonomic) of:a. ANS- palpitation, sweating, trembling, dry mouthb. Physical: SOB, choking, chest pain, nauseac. MSE: dizziness, DPR/DR, LOC, fear of dyingd. General: hot flushes, numbness, tinglinge. Tension: muscle tension, aches/ pains, restlessness,

edgy, lump in throat, dysphagiaf. Other: startle reaction, blank mind, irritability, insomnia

Generalised Anxiety Disorder…..

Comorbidity/ D/D:

• Other anxiety disorders • D & A abuse & withdrawal • Medications (CVS: AntiHT, antiarrhythmics, RS:

brochodilators,CNS: anticholinergics,AEDs, DA, Psychiatric: ADs, NLs, antabuse reaction, bezo withdrawal)

• GMCs (CVS: arrhythmias, MVP, CCF; RS: Asthma, COPD, PE; CNS: TLE, VBI; Endocrine: Hyperthyroidism, hypoparathyroidism, ↓sed BM, phaeochromocytoma Misc: Anaemia, porphyria, SLE, pellagra, Carcinoid)

GAD- Treatments

Psychological: less effective than in other anxiety disorders, CBT useful- education, cognitive remediation. BT- exposure, relaxation, control of hyperventilation.

Physical: ECT/ Psychosurg.- rare (severe intractable)

Pharmacological: directed towards symptom domains:a) Psychic- buspironeb) Somatic- benzosc) Depressive- TCAs, SSRIs, SNRIs, Mirtazepine, MAOIsd) ANS/CVS- β blockers

Case 2

• 35 YO married unemployed male with h/o ADS, presents with 12 yrs h/o cleaning & checking rituals, feeling hopeless & suicidal, homebound.

• Prev. treated with SSRIs, Antipsychotics - partial response, disengaged from CBT

• N. birth/early dev/schooling, graduated, worked as Real Estate manager till 25, unemployed & on DLA

Case 2…

• F/H/o: Depression in mom, strict parents- high expectations, 3 sibs-all perfectionists

• O/E:GPE- NAD, rough skin, mildly ↑sed AST/ALT• MSE: Pressured, agitated, restless, doubts re

contamination & need to check everything, no delusions/hallucinations, fleeting suicidality, no plans, MMSE- couldn’t complete as had to check frequently

Case 2

• Gp 2: Diagnoses/ diffrertials

• Gp 3: Aetiology

• Gp 4: Treatments

• Gp 1: Risks/prognosis

Obsessive Compulsive Disorders• Essence: a common chronic condition with obsessions &/or

compulsions causing severe distress .• Clinical features:

Obsessions Compulsions

a) Recurrent, persistent, intrusive, irrational thoughts/ impulses/ images causing severe anxiety

b) Person attempts to ignore/ suppress/ neutralize with some other thoughts or actions. Ownership maintained- not alienation

a) Repetitive behaviours/ mental acts in response to obsession or according to strict rules

b) Behaviours/ mental acts aim at preventing/ reducing distress or dreaded outcomes

OCD….

• Types: Check(63%), wash(50%), contamination (45%), doubt(42%), bodily fears (36%), count (36%), symmetry (31%), aggressive (28%)

• Epidemiology: Age- 20yrs, F=M, Prev. – 0.5-2%• Associations: Cluster C (40%), anankastic traits (5-15%),

Schiz. (5-45%), Sydenham chorea (70%), TS• Comorbidity: Dep.(50-70%), D & A, Soc. phobia, panic

dis, ED, tic disorder (40% Juvenile OCD), TS• D/D: Normal worries, anankastic PD, schizophrenia,

phobias, depression, hypochondriasis, BDD, trichotillomania.

OCD- Mx…..

A Psychological:1) Supportive: valuable, family, groups2) BT: ERP, Thought stopping (ruminations)3) CBT: Not proven effective, RET

B Pharmacological: a) SSRIs: 1st line, lag period (12 weeks), long termb) TCAs (CMI)/ MAOIsc) Augmentation: buspirone, antipsychotics, lithium

C Physical: ECT- suicidal, Psychosurgery- intractable (treatment resistant- 2 Ads, 3 Combinations, ECT & BT)- streotactic cingulotomy (65% success)

OCD- AetiologyTheories:1) Neurochemical: 5HT dysregulation, 5HT/DA interaction2) Immunological: CMI (against basal ganglia peptides)3) Imaging: CT/MRI- B/L reduction in caudate size PET/SPECT-

hypermetabolism in orbitofrontal gyrus & BG 4) Genetic: MZ: DZ= 50-80:25%, 3-7% 1st degree relatives5) Psychological: Defective arousal & / or inability to control

unpleasant, obsessions -conditioned stimuli, compulsions- reinforced learned behaviours

6) Psychoanalytical: regression, isolation, undoing & reaction formation

OCD…….

• Course: sudden onset, fluctuating/ chronic, • Outcome: 20-30% significant, 40-50%

moderate, 20-40% chronic/worsening. • Prognostic factors: A. Poor: giving in, longer duration, early onset,

bizarre compulsions, symmetry, comorbid depression, PDs (schizotypal),

B. Good: good premorbid social & occupational level, a precipitating event, episodic symptoms.

Case 3

• 22 YO single PG student presents with 3/12 h/o nightmares, flashbacks, panic attacks, fearfulness, insomnia, poor appetite, loss of conc. & enjoyment.

• Was mugged & date raped 4/12 ago, police arrested the culprits & she gave witness.

• N. Birth/early dev/schooling/peers/ good grades

• CSA: by elderly neighbour 7-8 yrs age

Case 3…

• No past/ family history• O/E: GPE- NAD, tremors & ↑sed HR• MSE: Anxious, guarded, slow to warm up,

describes flashbacks of incidents, low self esteem, no depressive/psychotic symptoms/signs, willing to engage in treatment.

Case 3…

• Gp 3: Diagnoses/ differentials

• Gp 4: Aetiology

• Gp 1: Treatment

• Gp 2: Risks/prognosis

Post Traumatic Stress Disorder (PTSD)

• Essence: Severe psychological disturbance following a trauma, involuntary re-experiencing with symptoms of hyperarousal, avoidance & emotional numbing.

• Symptoms/Signs: Onset within 6/12 (ICD10) of trauma, at least 1/12 with clinically significant distress or impairment in social, occupational or other important areas; 2 or more ‘persistent symptoms of ↑sed psychological sensitivity & arousal:

1. Initial/ middle insomnia2. Irritability/ anger outbursts3. Poor concentration4. Hypervigilance5. ↑sed startle response

PTSD- Aetiology• Psychological: ‘Remodeling of Underlying Schemas’-

requires holding of trauma experience in ‘active memory’ (working through). Dissociation protects from being overwhelmed.

• Biological: Neurophysiological changes → permanent neuronal changes (chronic/ persistent stress/ reliving). Neurotransmitters- NA/ 5HT/ GABA/ Endogenous opioids / glucocorticoids.

• Neuroimaging: ↓sed R hippocampal vol., dysfunction of amygdala & associated projections- ↑sed fear response

• Genetic: Higher concordance in MZ > DZ twins

• Epidemiology: Risk of PTSD (20-30%), Median(8-13%), Lifetime prevalence-7.8%, F: M= 2:1, Cultural differences +

• Risk factors: Vulnerability: low education, low SE class, Afro-Carribean /Hispanic, Female, low self esteem / neurotic traits, past/ family h/o psychiatric problems, previous traumas (CSA).

• Comorbidity: Depression, mood disorder, D & A, somatisation disorders.

• D/D: ASR/ D, Enduring personality change, adjustment dis., other anxiety dis., depression, mood disorder, OCD, schiz., D & A.

PTSD…..

PTSD- Management• Psychological:a) CBT: TOC- education, self monitoring, anxiety

management, exposure, cognitive restructuringb) EMDR: Voluntary multisaccadic eye movementsc) Psychodynamic: meaning & work through

• Phramacological: limited evidence, for comorbid1) Depression: SSRIs/TCAs/MAOIs2) Anxiety: Benzo/buspirone/ ADs3) Intrusive thoughts: CBZ, Li, Fluvoxamine

PTSD- Course & Outcome

50% recover in 1 yr, 30% chronic courseOutcome dependent on initial symptom

severityRecovery helped by: good social support,

absence of maladaptive coping, no further traumas, no D&A/Forensic

Q1. The ‘the sense of impending doom always’ is the main feature of which of the following:A.ManiaB.Alcohol withdrawalC.Generalized Anxiety DisorderD.Depression

MCQ 1

Q 2: Obsession is:

A. False, firm unshakable belief out of social/ cultural context

B. Own, Irrational, Repetitive, Intrusive egodystonic belief/ impulse/ image

C. Irrational fear of a specific situation/object causing avoidance

D. Perception without an external stimulus

MCQ 2.

Q 3: The main feature of PTSD is:A. Own, Irrational, Repetitive, Intrusive ego

dystonic belief/ impulse/ imageB. Reliving traumas with resultant arousal,

numbing and avoidance associated with trauma

C. Perception without an external stimulusD. Repetitive acts/thoughts to neutralize

anxiety caused by obsessions

MCQ 3.

Answers

• Q1. C

• Q 2. B

• Q 3. B

Thank You & Best Wishes !

Further reading• Oxford Textbook of Psychiatry, 5th Ed, Gelder M,

Harrison & Cowen P., Oxford University Press 2006• ICD 10- Clinical Description & Diagnostic Guidelines,

WHO 1994• DSM IV-TR- A Clinical Guide to Differential Diagnosis,

APA 1994, Revised 2004• The Maudsley Prescribing Guidelines, 10th Ed, Taylor

D, Paton C & Kapur S, Informa Healthcare 2009