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1. Neurotic, Stress Related Disorder
And Somatoform Disorder
By Nabina Paneru

2. NEUROTIC DISORDER
• Neurotic disorder (neurosis) is a less severe form of psychiatric disorder where,
patient show either excessive or prolonged emotional reaction to any given
stress.
• These disorder are not caused by organic brain disease & however severe, do no
involve hallucination and delusions.

3. Classification of Neurotic Disorder
• Generalized anxiety disorder
• Phobic anxiety disorder
• Dissociative (conversion) disorder
• Obsessive compulsive disorder
• Psychosomatic disorders
• Post traumatic stress disorder

4. Anxiety
• Anxiety is a normal emotional response (e.g. Apprehension, tension, uneasiness) to anticipation
of danger, the source of which is largely unknown or unrecognized.
• Anxiety may be regarded as pathologic when it interferes with effectiveness in living,
achievement of desired goals or satisfaction or reasonable emotional comfort.
• Anxiety may vary in mild, moderate, severe and panic depending upon its severity.

5. Anxiety disorders
• Are the group of conditions that are vague, subjective, non specific feeling of uneasiness, tension,
apprehension and sometimes dread or impending doom.

6. Generalized anxiety disorder
• This disorder is characterized by chronic, unrealistic, and excessive anxiety and worry.
• The anxiety is generalized and persistent not restricted to any particular environmental
circumstances (i.e. It is free floating).
• The symptoms must have occurred more days for at least 6 months
• It must cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

7. Epidemiology
• Prevalence of gad in general population: 3 to 8%
• Women to men ratio: 2:1
• About 25% of patients have generalized anxiety disorder in anxiety disorder clinics
• Onset: late adolescence or early adulthood

8. Etiology
Generalized anxiety disorder
Biophysiological
Cognitive theoryPsychodynamic theory

9. Etiology contd.
• Biophysiological theory
- Genetic evidence: about 15-20% of first degree relatives, monozygotic twins of patient is as high
as 80% i.e. 4 times more than in dizygotic twins.
- Biochemical: alteration in GABA and nor epinephrine level
- Substance intoxication and withdrawal (e.g. Cocaine, alcohol. Marijuana, opioids)

10. Contd.
• Psychodynamic theory: inability of ego to intervene when the conflict occurs between the id and
super ego producing anxiety.
• Cognitive theory: according to this theory anxiety is related to cognitive distortions, faulty or
counterproductive thinking patterns accompany (negative automatic thoughts) or precede
maladaptive behaviors and emotional disorders.

11. Sign and symptoms
• Physical symptoms
- Motor tension (restless fidgeting, tension, headache, trembling, twitching or feeling shaky, easy
fatigability)
- Autonomic and visceral symptoms: over activity, lightheadedness, sweating or cold calmy hands,
palpitation, tachycardia, flushes, dyspnea, SOB, tachypnea or hyper ventilation, constriction in the
chest or lump in throat, epigastric discomfort, nausea, abdominal distress, dizziness, dry mouth,
frequency of micturition, diarrhea, mydriasis etc.

12. Contd.
• Psychological symptoms
- Cognitive symptoms: distractibility, hyper arousal, vigilance, negative automatic thoughts.
- Perceptual symptoms: derealization, depersonalization
- Affective symptoms: diffuse, unpleasant, vague sense of apprehension, fearfulness, inability to
relax, irritability, feeling of impending doom (when severe)
- Other symptoms: insomnia, increased sensitivity to noise, worries prolonged and difficult to
control.
- Tension in the form of headache, restlessness or tremors

13. Management
• Pharmacotherapy
• Cognitive behavioral therapy
• Other psychological therapies
• Nursing management

14. Contd.
• Pharmacotherapy:
- Benzodiazepines (e.g. Alprazolam, clonazepam)
- Antidepressants for panic disorder and depression
- Beta blockers to control severe palpitations that have not responded to anxiolytics (e.g.
Propanolol)

15. Contd.
• Cognitive behavioral therapy
Behavioral therapy
- Relaxation technique
- Hyperventilation control
- Bio feedback
Psychotherapy : goal of psychotherapy is to increase the patient’s anxiety tolerance, rather than to
eliminate it by providing safe environment.

16. Contd.
• Other psychological therapies
- Jacob’s progressive muscle relaxation technique, yoga, pranayama, meditation and self hypnosis
- Supportive psychotherapy

17. Nursing management

18. PHOBIC ANXIETY DISORDER

19. Phobia
• Defined as an unreasonable fear of specific object, activity or situation.
• Phobia is an illogical, intense, persistent fear of a specific object or a social situation that causes
extreme distress and interferes with normal life functioning.

20. TYPES
• An irrational fear of performing activities in the presence of other peoples or interacting with others. Person is
afraid of his actions being viewed by others critically, resulting in embarrassment or humiliation.
• E.g. Fear of blushing (erthrophobia), fear of participating in group works, interacting with others, speaking to
authority figures, and urinating in a public lavatory (shy bladder).
Social Phobia
• Characterized by irrational fear of being in places away from the familiar setting of home, in crowds, or in situations.
• E.g. fear of entering in shops, public places, travelling alone in trains, buses, planes. As agoraphobia increases in
severity, there is gradual restriction in normal day to day activities.
Agoraphobia
• Irrational fear of a specific objects or stimulus, specified objects or situations.
Simple
phobia

21. Simple phobias
• Acrophobia: fear of heights
• Pteromerhanophobia: fear of flying
• Claustrophobia: fear of enclosed spaces
• Entomophobia: fear of insects
• Ophidiophobia: fear of snakes
• Cynophobia: fear of dogs
• Astraphobia: fear of storms
• Trypnophobia: fear of needles
• Hematophobia: fear of sight of bloods.

22. Etiology
• Biological theories
• Psychodynamic theory
• Behavioral theories

23. Contd.
• Biological theories: all phobias are closely linked to panic disorders and so genetic factors are also
linked to phobias
• Psychodynamic theory:
- focus on the inability of ego (primarily defense mechanisms) to intervene when the conflict occurs
between the id and super ego producing anxiety.
- In phobia secondary defense mechanisms of ego i.e. Displacement come into action. By using
displacement, anxiety is transferred from a really dangerous or frightening object to a neutral object.
These two objects are often connected by symbolic association.
- Traumatic experiences in childhood, like loss of parents in childhood are susceptible to anxiety and
fear in childhood and in later life.

24. Contd.
• Behavioral theories: it explain phobia as a conditioned reflex. Initially, the anxiety provoked by
a naturally frightening or dangerous object occurs in contiguity with a second neutral object. If
this happens often enough, the neutral object becomes a conditioned stimulus for causing anxiety.

25. General clinical features of phobias
• Presence of the fear of an object, situation or activity.
• The fear is out of proportionate to the dangerousness perceived.
• Patient recognized the fear as irrational and unjustified
• Patient is unable to control the fear and is very distressed by it.
• This leads to persistent avoidance of the particular object, situation, or activity.
• Gradually the phobia and the phobic object becomes a preoccupation with the patient, resulting in
marked distress and restriction of the freedom of mobility.

26. Diagnosis
• History taking
• Physical examination
• Mental status examination

27. Management
• Pharmacotherapy
• Psychotherapy
• Behavioral therapy
• Nursing management

28. Contd.
• Pharmacotherapy
- Benzodiazepines (alprazolam)
- Antidepressants (SSRI, TCA)

29. Contd.
• Psychotherapy: cognitive behavioral therapy
• Behavior therapy: flooding, systematic desensitization, exposure and response prevention and
relaxation techniques