neurotic disorders mrcpsych ii, ga module dr. naresh k. buttan m.b.b.s., d.p.h., d.p.m., d.n.b....
TRANSCRIPT
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