2. NEUROTIC DISORDER
It is a less severe form of psychiatric
disorder, in which the patients exhibit
excess or prolong emotional response to
the stressors and it is not due to organic
brain diseases
3. ICD-10 Classification of Neurotic, Stress-related and
somatoform disorder (F40-F49)
F40-Phobic anxiety disorder
F41-Other anxiety disorder
F42-Obsessive-compulsive disorder
F43 - Reaction to severe stress and adjustment
disorder
F44 - Conversion or dissociative disorder
F48-Other neurotic disorder
4. Causes of Neurosis
•Biological and environmental factors together
contribute neurosis, e.g. Faulty socialization,
defective role models, low socioeconomic status low
educational status
•Psychological factors
Maladaptive learning or defective learning
Threatening inner desires and impulses
Lack of stimulating environment
Strained or distorted interpersonal relation- ship
Stressful environment.
5. Types of Psychoneurosis
•Anxiety (is a feeling of fear, dread, and uneasiness)
•Phobia(is an excessive and irrational fear reaction)
•Hysteria(emotionally charged behavior that seems
excessive and out of control)
•Obsessive-compulsive neurosis(Excessive thoughts
(obsessions) that lead to repetitive behaviors
(compulsions)
6. •Dysthymia or reactive depression.
•Neurasthenia(an ill-defined medical condition
characterized by lassitude, fatigue, headache,
and irritability, associated chiefly with
emotional disturbance.)
• Depersonalization(occurs when you always or often feel
that you're seeing yourself from outside your body or you
sense that things around you are not real — or both. )
• Hypochondriasis
7. Manifestations
•Neurotic thoughts or behaviors that significantly
impair, but do not altogether prevent normal daily
living or daily functioning
•Mental imbalance that causes or results in distress
•Anxiety
•Sadness or depression, mental confusion
•Anger
8. •Low sense of self-worth
•Behavioral symptoms-phobic avoidance. vigilance,
impulsive, compulsive acts, lethargy
•Cognitive problems, e.g. unpleasant or disturbing
thoughts, repetition of thoughts and obsession, habitual
fantasizing, negativity, cynicism
•Interpersonal problems, e.g. Dependency,
aggressiveness, perfectionism, schizoid isolation, socio-
culturally inappropriate behaviors.
10. 2. Abreaction therapy
focuses on reliving a traumatic event and going through the
emotions associated with them to heal and move
forward.
3. Drug therapy
Desensitization-cognitive therapy-positive reinforcement (
exposure to the stimulus while positively reinforcing
tolerance of anxiety)
Assertiveness therapy( how to behave more boldly and
self-confidently)
Flooding or impulsive therapy(The patient is exposed
directly and rather abruptly to the fear-inducing stimuli
while at the same time employing relaxation techniques
designed to lower levels of anxiety)
11.
12. ANXIETY DISORDERS
Historical Perspectives
In 1871, Jacob Da Costa explained that chronic cardiac
syndrome had been included in psychological and
somatic symptoms among soldiers.
In 1900, Sigmund Freud introduced the concept of
anxiety.
Definition
Anxiety is defined as 'feelings of uncertainty,
apprehension uneasiness or tension that an individual
shows in a given situation
13. Epidemiology of Anxiety Disorders
•Anxiety disorders are more common in females.
•Lifetime prevalence of anxiety disorders are 25% in
females and 15% in males.
•Common anxiety disorder in female is specific phobia
followed by social phobia.
•Common anxiety disorder in male is social phobia.
•In general, anxiety disorders are early in onset when
compared with psychotic or mood disorders.
14. Onset of anxiety disorders
Disorders onset of the disorders
Specific phobia
Social phobia
Obsessive compulsive
disorder
Agoraphobia
Panic disorder
Generalized anxiety disorder
Post-traumatic stress
disorder
Childhood
Early teenage
Mid to late teenage
Early 20's age group
Mid 20's age group
Around 30 years of age
Depends on the exposure of
trauma
15. Causes
•Traumatic experiences
•Anxiety is a signal to the ego to take defensive action
against the 'pressure' from within (Sigmund Freud)
•Stimulation of autonomic nervous system and central
nervous system
•Genetic component, e.g. higher frequency of illness
was observed in first degree relatives of affected
persons than in the relatives of non affected persons
and in monozygotic twins
•Socio-cultural factors, e.g. faulty child rearing (bring
up and care for (a child) until they are fully grown)
practices
16. •Psychological factors-maladaptive responses, strained
interpersonal relationship, stress, unresolved conflicts,
disturbing memories, forbidden impulses, conflict
between id and ego
•Neurotransmitters and biochemical factors
Alpha-adrenergic agonists and alpha-2 adrenergic
antagonist can produce frequent and severe panic attacks
Serotonergic hallucinogens and stimulants.e.g. lysergic
acid diethylamide (LSD) and 3, 4 methylene
dioxymethamphetamine (MDMA) are associated with
the development of both acute and chronic anxiety
disorders .
17. Alteration in GABA levels
Increased levels of norepinephrine, serotonin.
•Behavioral factor: Unconditional inherent response of the
organism to painful stimuli
•Cognitive factor: Cognitive distortions; negative
automatic thoughts .
•Medications and substances which can induce anxiety
are: caffeine and other stimulants, drugs. e.g. heroin,
cocaine and amphetamines, decongestants, steroids, e.g.
cortisone, weight loss products, hormonal pills,
withdrawal from alcohol or benzodiazepines.
18. Etiology Based on the Types
•Social phobia: Individual feels humiliated in public
places.
•Specific phobia: Evolutionary phenomenon (For
example: Fear of dog - individual might have been
exposed to dog bite earlier or seen someone who suffered
from the same situation).
•Post-traumatic stress disorder: History of exposure to
traumatic event/events.
19. Continuum or Levels of Anxiety
The levels of anxiety include normal level, euphoria,
mild anxiety, moderate anxiety, severe anxiety and
panic anxiety
Normal: Individual may experience threat, but he/she
might take necessary steps to reduce the threat.
Euphoria: Exaggerate feel of wellbeing which is not
appropriate to the situation. It is an onset of mild level
of anxiety.
20. .Mild anxiety: Increased alertness towards inner feelings.
Client might be restless, unable to relax, maintain rigid
posture and tremulous motor activity.
Moderate anxiety: Signs like lack of concentration,
tremors in voice, physiological changes, pacing and
verbalizing about danger are observed.
Severe anxiety: Decreased intelligence, inability to
perform the task and inability to communicate clearly,
lack of concentration and decreased ability to perceive
things.
21. Panic anxiety: Altered physiological, intellectual and
emotional changes take place. Physiological changes
peak up and get back to normal within shorter duration
followed by a stressor.
Normal Euphoria Mild Moderate Severe Panic
22. Symptoms of Anxiety
It includes physiological symptoms, psychological or
emotional symptoms, behavioral symptoms and
cognitive symptoms.
24. Aspects Symptoms
Physiological symptoms Frequent urination
Increased sweat in palms
Sleep disturbances
Tightness of chest
Dyspnea
Weakness or muscle
tension
25. Aspects Symptoms
Psychological or
emotional symptoms
Depression
Irritability
Social isolation
Lack of interest
Anger
Crying spells (frequent or
uncontrollable Crying )
26. Aspects Symptoms
Behavioral symptoms Hyper vigilance
Restless
Pacing (to walk with
regular steps in one
direction and then back
again, usually because
you are worried or
nervous)
27. Aspects Symptoms
Cognitive symptoms * Lack of concentration
Inability to perform a task
as expected
Memory loss
Unresponsive to external
stimuli
Slow in performance
Preoccupied with
something
28. Clinical Features of Generalized Anxiety Disorder
•Prominent, persistent and exaggerated worry or tension
or apprehension about day to day problems or events.
•Restlessness
•Inability to relax
•Irritable
•Difficult to concentrate
• Initial insomnia (delay in falling into sleep due to
continuous worry)
•Muscle tension or tension headache
29. •Autonomic symptoms like palpitation, increased heart
rate, sweating, tremors, etc.
•Physical symptoms like abdominal discomfort, difficult
to swallow, lump in the throat, hot flushes, numbness or
tingling (numb)sensation, etc
30. Clinical Features of Panic Disorder
Episodes of panic attacks are characterized by:
•Acute onset of severe anxiety without an obvious trigger
•Anxiety symptoms and physiological changes might
reach at peak within few minutes and get back to normal
within few minutes
•Autonomic symptoms like palpitation, increased heart
rate, sweating, tremors, etc.
31. •Physical symptoms like chest tightness, breathing
difficulty, abdominal discomfort, difficult to swallow,
hot flushes, cold chills, lump in the throat, hot numbness
or tingling sensation, etc. flushes,
•Fear of dying, fear of losing control, fear of fainting
depersonalization and de realization may also be present.
32. Clinical Features of Post-traumatic Stress
Disorder
(PTSD)
•Symptoms of anxiety develop after an unexpected
threat or catastrophic event.
Examples: Road traffic accident, natural disaster,
physical or sexual abuse, strong psychological
trauma, etc.
•Individual relieves trauma by means of: Flashback
while awake. (Flashback is a sudden, powerful,
recurrent re-experiencing of the traumatic events)
33. Nightmares during sleep (A disturbing dream
associated with the negative feelings, such as anxiety or
fear that awakens the individual from sleep)
•Individual avoids the places, persons, situations which
may be associated with a particular trauma
•Hypervigilance: Hyperalertness to look out further
danger
•Startled easily
34. •Emotional numbness, irritability, insomnia, lack of
concentration, depersonalization and de realization might
be present.
•Rate of PTSD depends on the severity of the trauma
35. Clinical Features of Phobic Anxiety
Acute anxiety which has been precipitated by the
exposure of specific triggers
•In Initial phase: Individual tries to escape from
trigger
•In due course: Individual tries to avoid the trigger
• Symptoms of acute anxiety are same as for
symptoms in panic attack
36. Traumatic events might occur for individual and group
Individual Group
* Strong threat from stranger
Victim of sexual abuse
Physical abuse
Witness the severe accident
Involved in life-threatening
accident*
Domestic violence from life
partner
Natural disaster
Earthquake Tsunami
Man-made disaster
Bomb threat War
37. Types of Phobia
Social phobia: Fear of being a focus of attention, and
it further leads to avoidance of social situation such as
eating in hotel, using public toilets, delivering a
speech before the spectators, attending parties, etc.
Features in social phobia like avoidance of social
situations are similar to negative symptoms of
schizophrenia and schizoid personality. But in social
phobia, patient is unhappy or feels that fear is
excessive and unnecessary one whereas in negative
symptoms of schizophrenia and schizoid personality it
won't be as such.
38. Agoraphobia: Fear of going to public place, leaving
home and traveling alone or walking in crowds.
Simple or specific phobia: Assignment
39. Treatment
Drugs
•Benzodiazepines: Useful in simple or specific phobia
e.g. Lorazepam and Diazepam.
•Antidepressants: Selective Serotonin Reuptaek
inhibitors (SSRI) is the first-line treatment for anxiety
disorder (except simple or specific phobia e.g.
Fluoxetine and Escitalopram.
•Beta blockers: Useful for somatic symptoms anxiety
such as tremors, tachycardia, etc. for example,
Propranolol.
40. (For OCD Tab. Clomipramine can be given. In case of
treatment resistant OCD and SSRI augmented with low
dove antipsychotics can be given .Benzodiazepines might
be useful in short-term treatment and SSRI might be used
in long-term/maintenance treatment)
Psychotherapy
Cognitive behavior therapy: Maladaptive cognitions
imaginary threat has been identified and maladaptive
behavior (escape and avoidance to overcome anxiety has
to be changed.
41. Cognitive strategies-
•Help the client to have realistic perception of anxiety
• Educate the client that anxiety will not persist
forever and it might not kill
•Advise the client, avoidance of anxiety may help for
short-term reduction of symptoms but for long run it
won't help the individual, instead facing the anxiety
presently may worsen the symptoms but in long run it
might help to overcome the anxiety.
42. Behavioral strategies
Panic disorder: Cognitive Behavior therapy, Systematic
desensitization, relaxation training, stress management
strategies, maintaining the panic diary or journal writing
and special training to enhance the coping skills are
useful.
Phobia
Systematic desensitization: It is developed by Joseph
Wolpe. It has three steps:
•Relaxation training: Relaxation gives the physiological
effects which is opposite to the anxiety.
43. •Hierarchy Construction: Arrange the conditions in order
of increasing anxiety.
•Desensitization of stimulus: Gradual exposure of the
individual from least to most anxiety provoking state. In
fact it is a behavior modification technique that is used
especially in treating phobias, in which panic or other
undesirable emotional response to a given stimulus is
reduced or extinguished, especially by repeated exposure
to that stimulus. For example, to understand the concept of
systemic desensitization in an individual having fear of
crossing roads you can discuss the road signals, show the
picture of road, show the real road, assist the person to
cross the road and at last ask the individual to cross the
44. •Flooding: It is also called as implosive therapy. It is
used to desensitize the persons to phobic stimuli. It
differs from systemic desensitization. Instead of
working out in hierarchy of anxiety and instead of
provoking stimuli, the person is 'flooded' with the
continuous presentation of phobic stimuli until the
anxiety comes down. Flooding does not exist in
practice because this intense anxiety might be
dangerous to the individuals and it may lead to heart
attack or death. For example, if the individual is having
the fear of insect, then the individual is put into the
room with more number of insects in order to reduce
the phobia.
45. Cognitive behavior therapy for post-traumatic stress
disorder
•Identify the cognitive distortions
• Discussion about the trauma
•Exposure to remind the traumatic incidents (place,
activities, person, etc.) By imagination (or) Direct
confrontation
•Development of skills to deal with future trauma
•Eye movement desensitization and reprocessing for
PTSD
•Self-monitoring technique: Ask the patient to monitor
oneself when he/she becomes anxious
46. •Relaxation training: Mindfulness meditation, exercise,
yoga, progressive muscle relaxation, breathing exercises
and autogenic training
•Psycho education
•Problem-solving skill training
•Support group
•Bibliotherapy-Self-help books
