Understanding Neurotic, Stress-Related and Somatoform Disorders
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This document discusses various neurotic, stress-related and somatoform disorders including anxiety disorders, obsessive-compulsive disorder, dissociative disorders, and conversion disorder. It provides information on the symptoms, etiology, risk factors, and treatment options for these conditions. Key topics covered include the definition of anxiety and its various subtypes, the involvement of the serotonin system in OCD pathogenesis, the 5 stages of acceptance in bereavement, and that conversion disorder is more common in females and young patients.
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Understanding Neurotic, Stress-Related and Somatoform Disorders
- 1. Neurotic , stress related & somatoform disorders TONY SCARIA 2010 KMC
- 2. Anxiety • Anxiety • Unknown internal vague threat • Fear • Known external definite threat • Anxiety • Feeling of nervousness • Agoraphobia • Diarrhea • Increased frequency of micturition • Cold clammy skin • Hyper reflexia TONY SCARIA 2010 KMC
- 3. Anxiety disorders • Panic disorder • Agoraphobia • Specific phobia • Social anxiety disorder • Generalised anxiety disorder MC anxiety disorder TONY SCARIA 2010 KMC
- 4. Anxiety disorder • Mc of all psychiatric disorder TONY SCARIA 2010 KMC
- 5. Panic disorder • a/c intake of intense anxiety accompanied by felling of impending doom • Sudden onset of palipitation • Choking • Dizziness • Feeling of realty • Fear of dying /losing of control /going mad TONY SCARIA 2010 KMC
- 6. CF panic disorder • Discrete episodes of intense fear • Abrupt onset • Last for some minutes • Symptoms like palpitation /sweating /shortness of breath /chest constriction /impending doom TONY SCARIA 2010 KMC
- 7. • Mean age is 25 yrs • F>>M • NT involved • NE ,5HT & GABA ,cholecystokinin • DD • MI , angina , MVP, asthma,pulmonary embolism • Pheochromocytoma /hyperthyroidism /carcinoid syndrome /hypoglycaemia TONY SCARIA 2010 KMC
- 9. Rx • Pharmacotherapy • BZD & SSRI • Venlafexine buspirone & clomipramine • Psychotherapy • Cognitive behavioural therapy TONY SCARIA 2010 KMC
- 10. Generalised anxiety • Excessive generalised persistent anxiety for atleast 6 months • Not restricted to any particular situation • excessive worries • Free floating anxiety • Motor tension / restlessness • Rx • Jacobson progressive muscle relaxation • Pharmacology • BZD DOC • Buspirone • SSRI fluoxetine • SNRIvenlafaxine • TCA TONY SCARIA 2010 KMC
- 12. Phobias • Insight + neurosis • In phobia • Primary defense repression • Secondary defense displacement TONY SCARIA 2010 KMC
- 13. Types of phobia Agoraphobia Social phobia Specific fobia Commonest type of phobia Irrational fear of one or more social or performance situations • Public speech • Public drinking /eating Phobias limited to highly specific situationsCharacterised by irrational fear of being in places away from familiar setting of home & patient believes that he cannot escapr from this places • Crowd • Travelling alone TONY SCARIA 2010 KMC
- 14. Agoraphobia • Commonest type of phobia • Irrational fear of being in unfamiliar places (crowd /public /open space) from where it is not easy to escape to a safe place TONY SCARIA 2010 KMC
- 15. Rx of agoraphobia • PTx • BZD & SSRI • Cognitive behavioural therapy • Systemic sesensitisation • Exposure • Response prevention • Exposure • Response prevention • Flooding • Relaxation technique • Psychodynamic psychotherapy TONY SCARIA 2010 KMC
- 16. Claustrophobia • Fear of closed spaces • Fear of MRI machine TONY SCARIA 2010 KMC
- 17. Acrophobia • Fear of heights TONY SCARIA 2010 KMC
- 18. Animal type phobias • Ailurophobias • Fear of cats • sitophobias • Fear of dogs • Zoophobia • Fear of animals TONY SCARIA 2010 KMC
- 19. Social phobia • Social anxiety disorder • Fear of social situations • Including that involving contact with strangers TONY SCARIA 2010 KMC
- 20. Rx of phobia • PTx • BZD + SSRI + b blockers • Psychotherapy • Behaviour therapy most effective Rx • Systematic desensitisation • Best evidence in Rx of phobias • Exposed to least anxiety provoking stimulus fb muscle relaxation techniquemoves up • Therpaeutic graded exposure or in vivo exposure • No relaxation • Same as above • Flooding (implosion) • Phobic stimulus in its severe form • Modeling (participant modelling) • Therapist himself exposes to phobic stimulus & demonstrates this to the patient TONY SCARIA 2010 KMC
- 21. Desensitisation Flooding Exposure in everyday practise Aversion therapy Covert sensitisation Exposure can be gradual starting with situations that provoke little anxiety & progressing gradually through more difficult one Exposure is intensive from start which provokes maximum anxiety & is allowed to remain there until anxiety has diminished Intermediate in speed & intensity in desensitisation & flooding • Aversion therpay • Used to Rx conditions which are pleasant but undesirable • Pleasant stimulus is paired with unpleasant response (electric shock) Alcoholism Transvestism Homosexuality Other sexual deviation • When unpleasant stimulus is produced by fantasy instead of electric stimulus or drugs If relaxation technique is carried out with this systemic desensitisation TONY SCARIA 2010 KMC
- 22. Impulse • Sudden irrestible force compelling a person to the conscious performance of some action with out notice or forethought • Pyromania • Recurrent & purposeful setting of fire • Kleptomania • Recurrent stealing of objects • Suicidal / homicidal impulses • Trichitillomania • Pathological gambling • Excessive gambling economic troublesTONY SCARIA 2010 KMC
- 23. Obsessive compulsive disorder Obsessions • Recurrent & intrusive thoughts images or impulses which can cause marked anxiety or distress • Insight + • Product of their own mind • Irrational & senseless • Ego dystonic (unwanted & unacceptable) Compulsions • Repetitive behaviours (hand washing or checking) • Done to reduce the distress & anxiety TONY SCARIA 2010 KMC
- 24. OCD may be accompanied with depression TONY SCARIA 2010 KMC
- 25. Etiology • Serotonin dysregulation • dysfunction of Cortico – striatal – thalamic cortical (CSTC) circuit OCD TONY SCARIA 2010 KMC
- 26. 4 types • Contamination • Pathological doubt • Intrusive thoughts • Symmetry TONY SCARIA 2010 KMC
- 27. Contamination Pathological doubts Intrusive thoughts (pure onsessions) Symmetry Most common pattern of obsession followed by washing Compulive checking Intrusive obsessional thoughts with out a compulsion (repitious thoughts of a sexual or agrreive act) Obsession of symmetry followed by compulsion of slowness TONY SCARIA 2010 KMC
- 28. Contamination • Obsession of contamination • Frequent hand washing TONY SCARIA 2010 KMC
- 29. Pathological doubt • Obsession of doubt • Compulsion of checking TONY SCARIA 2010 KMC
- 30. Intrusive thoughts • Intrussive obsessional thoughts • Sexual & aggressive content TONY SCARIA 2010 KMC
- 31. Symmetry • Need for symmetry or precision • Compulsion of sloweness TONY SCARIA 2010 KMC
- 32. Neuroanatomy in OCD • Orbitofrontal cortex cingulate gyrus basal ganglia (caudate nucleus)thaamus Serotonergic system is involved in pathogenesis TONY SCARIA 2010 KMC
- 33. Rx of OCD Pharmacotherapy Behaviour therapy Psychotherapy Psychosurgery SSRI Fluoxetine • Exposure & response prevention most commonly used • Systemic desensitisation • Flooding • Psychoanalytic psychotherapy • Suppotive psychotherapy must include attention to family members • Cingulotomy • CapsulotomyTCA Clomiprmaine Others • Li • Venlafaxine • Pindolol • MAOI • Carbamazepin e • Valproate TONY SCARIA 2010 KMC
- 34. Rx of OCD • PTx • SSRI clomipramine • Augment with haloperidol • Li/venlafaxine /carbamazepine/valproate • Psychotherapy • Exposure and response prevention • Exposure to stimulus which causes obsession and prevent response • Other Rx • Psychosurgery • Cingulotomy & capsuotomy (subcaudate tractotomy )TONY SCARIA 2010 KMC
- 35. Stress disorders TONY SCARIA 2010 KMC
- 36. Hans selye stress adaptation Alarm phase resistance phase exhaustion phase TONY SCARIA 2010 KMC
- 37. Stress disorder Acute stress disorder Post traumatic stress disorder Symptoms last <1 month Symptoms last > 1 month TONY SCARIA 2010 KMC
- 38. Post traumatic stress disorder & a/c stress disorder • Following a stress (war earth quake floods rape serious accidents ) life threatening event • Intrusion symptoms • Cb flashbacks (as if trauma is reoccurring) • Night mares (dreams about the trauma) • Avoidance • Avoid all those stimuli which can remind of trauma • Hyper Arousal symptoms • Hypervigilance / exaggerated startle response/insomnia / poor concentration TONY SCARIA 2010 KMC
- 39. Post traumatic stress disorder • Emotional numbing • Emotional detachment • Anhedonia • Derealisation • depersonalisation • If symptoms appear > 6 months delayed onset • <1mth a/c stress disorder TONY SCARIA 2010 KMC
- 40. Stressors for PTSD • Extreme traumatic events involving threat of personal death or injury • Symptoms of PTSD with in 6 months of stressor TONY SCARIA 2010 KMC
- 41. Risk factor & protective factor for PTSD Risk factors Protective factors • Low education • High IQ • Female • Male • Lower social class • Higher social class • Previous h/o psychiatric problems(mood /anxiety disorders) • External locus of control • internal locus of control TONY SCARIA 2010 KMC
- 42. PTSD • Increased NE inAmygdala & hippocampus are involved • Noradrenenrgic system • Opiod system • hypothalamic pituitary axis TONY SCARIA 2010 KMC
- 43. Rx of PTSD • SSRI • Cognitive behaviour therapy • Rx of choice • Psychodynamic psychotherapy • Eye movement desensitisation & reprocessing (EMDR) TONY SCARIA 2010 KMC
- 44. Adjustment disorder • Stressor • Financial issue • Medical illness of self or beloved ones • Relationship problems (divorce/ break up) • Development of emotional or behavioural problems with in 3 months of onset of stressor • Shouldnot persist > 6 months if stressor is terminated TONY SCARIA 2010 KMC
- 45. Symptoms of adjustment disorder Disturbance in emotions Disturbance in conduct Depressive Anxious Conduct • Low mood • Lack of interest • Hopelessnes s • Lethargy • Suicidal attempt • Anxiety • Irritability • Palpitation • Tremor • Aggressive or dramatic behaviour TONY SCARIA 2010 KMC
- 46. Adjustment disorder • In adolescent females • Maladaptive response to stressful stimuli • Depression , anxiety worry & feeling of inability to cope • Symptoms should start with in 3 months & should not last more than 6 months • Rx • Psychotherapy TONY SCARIA 2010 KMC
- 47. Bereavement & grief Death of beloved one Bereavement Symptoms d/t bereavement Grief Normal grief resolve with in 6-12 months TONY SCARIA 2010 KMC
- 48. CF of pathological grief • Intrusive thoughts of deceased person which produces anxiousness & depressive symptoms • Preoccupation with thought of deceased • Patient may see or hear voice of deceased TONY SCARIA 2010 KMC
- 49. Rx of pathological grief • Antidepressants TONY SCARIA 2010 KMC
- 50. 5 stages of acceptance TONY SCARIA 2010 KMC
- 51. CONVERSION DISSOCIATION TONY SCARIA 2010 KMC
- 53. Dissociative disorders /hysteria • Symptoms are produced unconsciously and help the patient to get attention • c/b disturbance in one or mental function (memory /identity/perception/consciousness) TONY SCARIA 2010 KMC
- 54. • Primary gain • refers to internal psychological motivation • As he is nt able to work Feels guiltdevelops paralysis (now patients patients guilt decreases as it is understood that paralyzed patient can’t work) • Secondary gain • Refers to external psychological motivation • Paralyzed patient need not work and he is relieved of his duties • Tertiary gain • Gain that a third person derives bcz of patients symptoms • As he is paralysed his family receives lots of money from relatieves TONY SCARIA 2010 KMC
- 55. Dissociation Dissociative amnesia Dissociative fugue Conversion • Circumscribed loss of traumatic memory • Purposeful wandering • Forgetting identity • Bizzare neurological sensory / motor symptoms TONY SCARIA 2010 KMC
- 56. • Dissociative amnesia • Loss of memory • Amnesia of traumatic events of personal significance • Eg : rape survivor not able to recall any thing about rape TONY SCARIA 2010 KMC
- 57. • Dissociative fugue • sudden unexpected travel away form home or work place with inability to recall some or all of one’s past • Basic self care is maintained • Even assume a new identity TONY SCARIA 2010 KMC
- 58. • Dissociative identity disorder • Multiple personality disorder • 2 or more distinct personalities exist • Personalities are unware of each others existences TONY SCARIA 2010 KMC
- 59. • Dissociation of trance & possession • Loss of sense of identity and full awareness of the surroundings • Middle aged women claimed that she has been possessed by a goddess and demanded that everybody should pray in front of her TONY SCARIA 2010 KMC
- 60. • Dissociative stupor • Patient is in stupor • Caused by psychological factors TONY SCARIA 2010 KMC
- 61. • Depersonlisation or derealisation disorder • Feeling of unrealty of self • He feels external world is unreal • He feels as if he has changed • he feels as if he has detached from his body and are watching themselves like in movie TONY SCARIA 2010 KMC
- 62. Gansers syndrome • Approximate answers are given • Indicating that qstn was understood • Frequently seen in prisoners • But not confined to them TONY SCARIA 2010 KMC
- 63. • Dissociative disorders of movement & sensation • Presents with symptoms that suggest deficit in motor or sensory functions • No evidence of physical disorder • Dissociative motor • Ataxia paralysis • Dissociative sensory • Sensory loss • Dissociative seizures TONY SCARIA 2010 KMC
- 64. Conversion disorder • Mc in female & young age TONY SCARIA 2010 KMC
- 65. Conversion disorder • Presence of symptoms or deficits affecting motor or sensory function suggesting a medical or neurological disorder. autonomic nervous system is not typically involved • Sudden onset. • Development of symptoms usually in the presence of a significant psychosocial stressor temporal relationship between stressor & development or exacerbation of symptoms. • Detailed physical examination do not reveal any abnormality that can explain the symptoms adequately. • Patient does not intentionally produce symptoms • Astasia – abasia (Blocq’s disease) Inability to walk or stand in a normal manner. The Gait is bizarre and is not suggestive of any organic lesion. • Primary & secondary gain + • “Labella” indifference: no regard for symptoms though look severe i.e. emotions are not matching with loss. Labella - is a french word meaning emotion. i.e emotions are not matching with the loss. TONY SCARIA 2010 KMC
- 66. Symptoms of conversion disorder Sensory symptoms Motor symptoms Seizure symptom patient presents with sensory loss which is not substantiated on physical examination. • Anaesthesia & paraesthesia MC • Not consistent with dermatomes loss of ability to move limb / in coordination etc • Atasia abasia • Gait disturbances • Usually in presence of family members / friends, • no injuries/frothing incontinence, last more than 1 min, not stereotyped, never in sleep TONY SCARIA 2010 KMC
- 67. Astasia abasia / blocqs disease in conversion disorder Inability to walk or stand in a normal manner. The Gait is bizarre and is not suggestive of any organic lesion. TONY SCARIA 2010 KMC
- 68. La belle indifference is also seen in • Multiple sclerosis • Parietal lobe lesion • Dissociative disorder • Physical illness TONY SCARIA 2010 KMC
- 69. Primary gain secondary gain in conversion disorder • Primary Gain - Relief from Unconscious signal Anxiety. • Subconscious • Defense mechanism • Secondary Gain - Observable Gain or some benefit is called a secondary Gain. • Gains attention & care • Relief from responsibilities • Tertiary gain to others TONY SCARIA 2010 KMC
- 70. • Functional neurological symptom disorder / conversion disorder • La belle indifference ‘ • Feeling of indifference which patients with conversion disorder have towards their symptoms • Patient will not be concerned about it TONY SCARIA 2010 KMC
- 71. Rx • Emphasise patient is normal • Avoid secondary & tertiary gains • Pychotherapy • Behavioural therapy • Abreaction • Attempt is made to bring unconscious memories & emotions to conscious awareness using hypnosis medications & other techniques TONY SCARIA 2010 KMC
- 72. Somatoform disorders TONY SCARIA 2010 KMC
- 73. Somatoform disorders • Typically present with physical symptoms which cant be explained by any medical condition • Types • Somatization • Undifferentiated • Hypochondriasis • Body dysmorphic disorder • Somatoform autonomic dysfnction • Persistent somatoform pain disorder • Pseudocyesis TONY SCARIA 2010 KMC
- 75. Somatization disorder Aka somatic symptom disorder Multiple physical symptoms for which no medical cause Patient refuses to accept the advice or reassurance of the doctors Symptoms appear in close relationship to upleasant life events • 4 pain symptom • Pain at 4 different sites • 2 gastrointestinal symptoms • Nausea vomiting belching • One sexual symptom • Erectile dysfunction • One pseudoneurological symptom • Weakness visual disturbances TONY SCARIA 2010 KMC
- 76. Somatisation • Defence mechanism used in somatoform disorder is somatisation • If stress+ present with multiple systemic somatic symptoms TONY SCARIA 2010 KMC
- 77. Somatoform disorder • Preoccupied with symptoms • Dramatisation + • Multiple recurrent somatic symptoms TONY SCARIA 2010 KMC
- 78. Undifferentiated somatoform disorder • Multiple physical symptoms + but full picture of somatization disorder is not fulfilled TONY SCARIA 2010 KMC
- 79. Hypochondriasis • Aka Illness anxiety disorder • Aka medical student disorder • 6 months of symptoms • Preoccupation with the fear of having one or more serious physical illness • In hypochondriasis preoccupied with disease • Somatization disorder is preoccupied with symptoms • Despite normal investigations move from doctor to doctor • Unlike in delusion • Here the belief is not fixed • Its fixed & unshakable in delusion TONY SCARIA 2010 KMC
- 80. Body dysmorphic disorder • Dysmorphobia • Preoccupation with an imagined defect in body appearance • Or exaggeration of slight physical anomaly • Usually in hair nose and skin • Hampers routine functionality TONY SCARIA 2010 KMC
- 81. Somatoform autonomic dysfunction • Specific & unexplained autonomic symptoms such as palpitation tremors sweating belching TONY SCARIA 2010 KMC
- 82. Persistent somatoform pain disorder • Persistent & unexplained pain TONY SCARIA 2010 KMC
- 83. Pseudocyesis • Patient has a false belief that she is pregnant • Associated objective signs • Distended abdomen (umbilicus does not become inverted) • Amenorrhea • Subjective fetal movements • Breast engorgement • Labour pains TONY SCARIA 2010 KMC
- 84. Factitious disorder • Munchausen syndrome • Hospital addiction / hospital hoboes or professional patient • Deliberately create symptoms • For seeking medical attention • Travels form doctor to doctor hospital to hospital • Patient has eagerness to undergo various test investigations & procedures grid abdomen • Distort clinical histories ,laboratory test reports TONY SCARIA 2010 KMC
- 85. Grid iron abdomen with multiple scars in a pt with munchaussens syndrome TONY SCARIA 2010 KMC
- 86. Munchausen syndrome by proxy • In which a parent usually mother or care taker repeatedly fabricates or actually inflicts injury to child TONY SCARIA 2010 KMC
- 87. Malingering • Deliberately fake symptoms for a conscious apparent reason • Recognizable external motive • Intentional production of false or exaggerated symptoms TONY SCARIA 2010 KMC
- 89. Other neurosis TONY SCARIA 2010 KMC
- 90. Neurasthenia • c/o of increased mental & physical fatigue after mild efforts • Patient is often concerned about lowered physical & mental efficiency • Muscular aches / pain/sleep disturbances/irritability/dyspepsia/headache /inability to relax TONY SCARIA 2010 KMC
- 91. c/c fatigue syndrome • Myalgic encephalomyelitis • In western countries • Severe debilitating fatigue • Malaise • Head ache pharyngitis • Tender LN • GI symptoms • Low grade fever TONY SCARIA 2010 KMC
- 92. Culture bound syndromes • Limited to some cultures • Dhat syndrome • In indian subcontinent • Feeling of Passing semen in urine physical & mental weakness • Koro • In south east asia • Fear that his penis retracts into abdomen death • Latah • In Malaysia • Automatic obedience • Echolalia/echopraxia • Amok • In philipiness • Brooding followed by homicide Koro Dhat syndrome TONY SCARIA 2010 KMC
- 93. Factitious disorder • Munchausens syndrome • Hospital addiction • Professional patients • Often from medical & related fields • Produce fake symptoms for attaining medical attention • In malingering • Distort the history & make stories (pseudologia fantasica) TONY SCARIA 2010 KMC
- 94. Psychosomatic disorders TONY SCARIA 2010 KMC
- 95. General adaptation syndrome (GAS) TONY SCARIA 2010 KMC
- 96. Selyes stages of GAS TONY SCARIA 2010 KMC
- 97. Alarm reaction • Characterised by flight or fight response Stage of reistance • Stage of adaptation • Body adapts to stress Stage of exhaustion • Resistance of body gradually decreases TONY SCARIA 2010 KMC
- 98. Psychosomatic manifestation • Gastrointestinal system • Peptic ulcer / crohns d/s /ulcerative colitis • Irritable bowel syndrome • Abdominal pain cramps • Alteration of bowel habits • Respiratory system • Asthma COPD • hyperventilation syndrome • Rapid & deep breathing for several minutes • Accompniying symptoms of suffocation / giddiness /paraesthesia/ syncope (due to falling pCO2) TONY SCARIA 2010 KMC
- 99. • Cardiovascular system • HTn • CAD • Type A personality • Cardiac arrhythmias TONY SCARIA 2010 KMC
- 100. Musculoskeletal system • RA • SLE • Fibromyalgia • Pain & stiffness of muscle ligaments • Anxiety fatigue inability to sleep • Local areas of tenderness TRIGGER POINTS TONY SCARIA 2010 KMC
- 101. Rx of somatoform disorders • Resist psychiatric rx • Psychotherapeutic techniques • Grp psychotherapy • Behaviour therapy • Insight oriented psychotherapy • Relaxation technique • Stress management TONY SCARIA 2010 KMC
- 102. • Bereavement • State of being deprived of some one d/t death • Grief • Psychological feeling precipitated by death of a loved one • Mourning • External exression of grief through funeral rituals TONY SCARIA 2010 KMC
- 103. Elizabeth kubler model of grief / death &dying TONY SCARIA 2010 KMC