Dr Ben Green,
Consultant in Psychological Medicine
Halton Hospital, Runcorn,
Neurotic disorders are a collection of psychiatric disorders without psychotic symptoms and lacking the intense psychopathology of, say, hypomania or major depression. Having said this, neurotic disorders are a major source of suffering to individuals, their families and to society. The cost of treating alll neurotic disorders would be substantial, but the cost of non-treatment to society (in terms of lost production and lost efficiency) is probably greater. According to Croft-Jeffreys & Wilkinson (1989) the estimated cost to the UK of neurotic illness in 1985 was 373,000,000. A decade later the sum must exceed half a billion pounds a year. After all, over a third of sickness certificates are for psychiatric illness, much of this being neurotic, (Jenkins, 1985). The persistent nature of anxiety disorder over time ,with its childhood antecedents and often recurrent prognosis, means that it may dominate sufferer's lives, (Angst & Vollrath, 1991). Only chronic heart disease produces more disability.
Many psychiatric disorders in the community do not fit comfortably into the traditional psychiatric classification systems, which are largely developed using secondary and tertiary care patients. In primary care many patients have symptoms of anxiety and depression. Therefore these pages ought to be read in conjunction with the treatment recommendations in the section on depressive disorders.
Generalised Anxiety Disorder (GAD)
GAD may affect up to 5% of the general population. The classical syndrome of generalised anxiety disorder involves both psychological and somatic symptoms (Rapee, 1991). Psychological symptoms include free-floating anxiety (ie anxiety not attached to any particular object or event) and a fearful preoccupation with the future. Somatic symptoms include tachycardia, palpitations, essential tremor, muscular tension, hypertension, dizziness, sweating, hyperventilation, and epigastric discomfort. Anxiety is often a presenting symptom of depressive illness, and it is sometimes difficult to disentangle the two.
Brief counselling and training in problem-solving techniques may enable general practitioners to help patients with GAD without resorting to anxiolytics and apparently without increasing demands on precious GP time (Catalan et al, 1984 & Andrews, 1991). Self-help programmes for anxiety disorder using anxiety management booklets have been found effective, (Sorby, Reavley, & Huber, 1991). General practitioners welcome clinical psychologists' help in the management of anxiety disorders, and desire an increased availability of clinical psychology services, (Deans and Skinner, 1992). Useful drug treatments for anxiety include short courses of benzodiazepines, and antidepressants such as paroxetine. Efforts have been made to reduce the use of benzodiazepines in general practice, and these have been successful, (Tiller, 1994). Even so, in the quest to alleviate anxiety disorders, doctors should be careful not to rely purely on drugs or psychological treatment. As Tiller comments, 'doctors should avoid stigmatising people with mental illness by implying that everybody should be able to overcome mental distress without the need for drugs'.
In a study comparing cognitive therapy, analytic psychotherapy and anxiety management training in the treatment of GAD, cognitive therapy appeared to be significantly more effective, (Durham et al 1994). There was no indication that longer courses of therapy were more effective than a basic 8-10 sessions.
Agoraphobia A fear of the market place, of crowds, of travelling on public
transport, and an avoidance of social situations and a marked tendency to stay at home,
rarely, if ever, venturing outside. Three quarters of sufferers are women. Behavioural therapy can be very successful, based on exposing the
patient to a graded hierarchy of situations ranging say, from a walk of ten yards away
from the front door to a day out in town. Often the patient's partner can be enrolled as a
co-therapist. Antidepressants, including MAOIs, may be particularly useful. Some patients
may reluctant to give up their illness behaviour, because there may be considerable
psychological rewards attached to it eg making the partner more attentive. Social phobias These involve the fear of meeting people, or the fear of behaving in
an out of the ordinary way in company. Whereas the agoraphobic is frightened of people in
the mass, the social phobic is also often afraid of one-to-one interactions with others.
Alcohol or benzodiazepines are often abused to reduce anxiety ahead of the event.
Anticipatory anxiety impairs performance in the feared situation leading to a cycle of
reduced confidence and increased anxiety before the next meeting and so on.
A fear of the market place, of crowds, of travelling on public transport, and an avoidance of social situations and a marked tendency to stay at home, rarely, if ever, venturing outside. Three quarters of sufferers are women.
Behavioural therapy can be very successful, based on exposing the patient to a graded hierarchy of situations ranging say, from a walk of ten yards away from the front door to a day out in town. Often the patient's partner can be enrolled as a co-therapist. Antidepressants, including MAOIs, may be particularly useful. Some patients may reluctant to give up their illness behaviour, because there may be considerable psychological rewards attached to it eg making the partner more attentive.
These involve the fear of meeting people, or the fear of behaving in an out of the ordinary way in company. Whereas the agoraphobic is frightened of people in the mass, the social phobic is also often afraid of one-to-one interactions with others. Alcohol or benzodiazepines are often abused to reduce anxiety ahead of the event. Anticipatory anxiety impairs performance in the feared situation leading to a cycle of reduced confidence and increased anxiety before the next meeting and so on.Obsessive-compulsive disorder (OCD)
Obsessional ideas are thoughts that come repeatedly into a person's mind, and which have some undesirable quality fas far as that person is concerned. The ideas may be nonsensical, say, or violent or obscene; such as ideas about harming a baby in a new mother or swear words repeatedly coming into the mind of a priest. Obsessional ideas are sometimes called intrusive thoughts.
Patients may describe intrusive thoughts as being like a conversation in their head. The key points to distinguish these intrusive thoughts from hallucinatory voices are that they:
The intrusive thoughts are not delusional either because although the thoughts are often incorrect the patient may volunteer how absurd the thoughts are. In other words they have insight into the nonsensical nature of the ideas.
Compulsive acts or rituals may be performed to reduce the anxiety associated with obsessional thoughts. For example the person who continually fears contamination may wash and re-wash their hands many times a day, even to the point of breaking the skin down. Compulsive acts and rituals are sometimes perfomed to ward off some undesirable event.
Performance of these rituals may interfere with everyday life. A patient who repeatedly spends two hours washing and showering after a toilet break at work may lose their job.
As with other neurotic disorders there is an overlap with depressive illness (since depressive illness may have obsessional features).
Obsessional personalities are essentially meticulous and perfectionistic workers who, if given a deadline will work to it, but who may expend great effort in getting things just right. Their attention to detail may infuriate those around them.
In terms of treatment at least 50% of patients with OCD can be treated using drugs such as fluoxetine and clomipramine. In patients who can accept it behavioural treatment with exposure and response prevention has a high success rate.
Imagine the mind has many layers of awareness. In clear consciousness we are aware of our surroundings and our inner thoughts usually at all levels. A thought which occurs at one level is usually apparent throughout the system. The sensation of hunger at one level is accompanied by fantasies of food and plans of how to get that food at other levels. At other levels of the mind memories of past meals and events might be triggered too. Somehow the thoughts, memories and sensations on all these levels are integrated.
In dissociation disorders we might imagine that somehow the layers are not being integrated properly, so that there are discrepancies or dissociations between the thought activity at different levels. Some people speak of a 'splitting of the stream of consciousness'. An example of this dissociation might be that some memories are strikingly unavailable to the conscious individual. Hypnotic or trance-like states, and depersonalisation episodes are other examples of dissociation.
When something extremely unpleasant happens dissociation may be a way of coping. Children who are being abused often feel as if the abuse is not happening to them, but to somebody else. They feel removed from it all. When the abuse is not happening it may be difficult for them to access the memories and feelings they had whilst they were being abused. Sometimes these split-off memories may only be acknowledged by an abused individual years later. The information about the unpleasant event is not lost, but is stored at some relatively inaccessible level to protect the sufferer from hurt. A further example of dissociation is the phenomenon in battle where a soldier running across a battlefield is shot at, but continues running oblivious of the bullet that has entered him. Only when he returns to safety can he begin to feel the pain and acknowledge the wound he has sustained.
The lack of integration caused by dissociation may produce a number of related disorders. Sigmund Freud described a variety of cases, then diagnosed as hysteria, but which now attract the diagnosis of dissociative conversion disorders. An example might be a young patient who has no physical abnormality, but who is adamant that they are unable to walk. The patient may undergo many diagnostic tests, but no abnormality is found. Other patients may present with atypical pains that defy our knowledge of human anatomy. Catharsis, an emotional return to the original traumatic event, via psychotherapy, hypnosis, or drug abreaction (provoked by intravenous diazepam, say), may release the patient from their symptom. Often the symptoms have some symbolic meaning, so that a child who is frightened to speak out against the abuser may develop an aphonia (an inability to speak), i.e. the trauma is 'converted', hence the term conversion disorder.
Not all patients have the ability to formulate psychological distress in psychological or emotional terms. They may present their inner conflicts an distress as physical symptoms. At a basic level this may be 'a way in' to discussing their problems with their doctor, but at another level the patient may be quite unable to accept a psychological basis for their illness at all.
In somatization disorder a patient may take their somatic symptoms from doctor to doctor in a vain attempt to find some test, investigation or cure that has not been offered elsewhere. Many negative investigations and therapies may have been tried by past doctors to no avail. Symptoms may involve any bodily system and may include gastric pain, belching, vomiting, nausea, itching, burning, tingling, numbness and fatigue amidst others.
Was Elizabeth Barrett Browning, the poet, a sufferer of somatisation disorder?
Almost a fifth (18.3%) of 15283 respondents to a questionnaire sent to patients of 6 English general practices described substantial fatigue lasting 6 months or longer, (Pawlikowska et al, 1994). The fatigue was positively correlated both with psychological morbidity and psychosocial causes.
About a quarter of patients attending primary care clinics display features of somatisation, (Kirmayer & Robbins, 1991). Somatisers place doctors in a real dilemma. There is a temptation to pursue countless costly investigations to get a diagnosis, based on the knowledge that rare syndromes can sometimes present in such unorthodox ways. There is also a temptation to do nothing and wash one's hands of such difficult patients. Usually there is a deal of anxiety about when to stop physical investigations and begin psychological therapies. Patients usually have a deal of depression and anxiety themselves. Specific antidepressant therapy may be warranted. In terms of aetiology recent life events may trigger episodes of somatisation in vulnerable people, and somatisation as a 'coping mechanism' more often occurs in those who had physical illness as a child and whose parents often had problems themselves, (Craig et al, 1994)
Confronting somatisers with 'reality' is rarely helpful. They have usually received multiple reassurances that there is no physical explanation for their symptoms and resent the implication that they are not telling the truth. Attempting to help the patient link the development and fluctuation of symptoms to life events and circumstances may produce results. However, the patient must 'own' the link themselves. It is no good for the doctor to present the entire theory out of the blue. It will not be accepted.
The psychological factors in the presentation of somatic symptoms are apparently often underestimated by primary-care doctors (and vice-versa for psychiatrists), but an 8-week teaching package involving a re-attribution model for symptoms, and using small group techniques, role play and video training has been shown to improve recognition and management skills (Kaaya et al, 1992 & Gask et al, 1989 ). The re-attribution model seeks to move away from a dialogue about physical causes for physical symptoms, and whilst acknowledging the reality of the symptoms, looks at the psychological factors that make them better or worse. Four stages have been identified (Goldberg et al, 1994):
This model is easy to state, but is less easy to practice. Difficulties often arise around the first and second stages, particularly if the patients feels that the doctor is being insincere or implying that the patient is being 'economical with the truth'. This is one reason why training groups can be useful in learning how to use the model effectively. Besides the re-attribution model, pain management, cognitive-behavioural therapy and group therapy have also been shown to be useful in managing somatisation.
Somatisation and psychiatric disorders are seen in all secondary care settings. Psychiatric disorders occur in about 15% of general medical out patients and in almost a third of medical out-patients there is some degree of somatisation. Adjustment disorders
The time used to turn life round after an adverse life event can be referred to as a period of adjustment and, if pathologically intense or persistent, the condition asociated with this time an adjustment disorder. The onset of the disorder is within a month of the event and the duration of symptoms is usually less than six months. Problem-solving and counselling may assist recovery. If the disorder persists the diagnosis may be that of a depression.
Post-traumatic stress disorder
After being involved in or witnessing severe life-threatening accidents or traumas, victims may suffer with a post-traumatic stress disorder, (PTSD). PTSD is common in soldiers and it has been described in various wars. During the first world war it was known as 'shell shock'. Symptoms of PTSD include episodes of re-living the trauma. Re-living may occur in flashback sequences during the daytime or as vivid recurrent dreams during sleep. Other symptoms include hyperarousal, insomnia, social withdrawal, numbness, fear and avoidance of cues that trigger memories of the event. Re-living the trauma may be associated with anxiety, fear and aggression.
Depression may co-exist with PTSD. Patients may also self-medicate with alcohol and substance abuse problems are often associated with the disorder. Antidepressant therapy may be helpful. Counselling as a matter of course is often offered to victims of disasters and those who witness them (e.g. stadium fires, crowd disasters). Repeated rehearsal of the trauma in continuing therapy may not be helpful and there is evidence to show that psychological debriefing after traumatic experiences does not prevent subsequent psychiatric morbidity, although such debriefing may initially be valued by the survivor, (Deahl et al, 1994)
Neurotic disorders probably account for about 60% of all psychiatric cases seen in primary care, (Shepherd et al, 1966). Mann et al (1981) and Huxley et al (1979) looked at non-psychotic illnesses presenting to the general practitioner and found that after one year about a quarter had improved, half had shown a variable course and a quarter had run a chronic course. Good outcome is promoted if the patient has a stable, supportive family life. Physical illness, old age, inadequate social support and initial severity all tend to predict poor outcome.
In epidemiological terms neurotic disorders have been associated with increased mortality from all causes over a period as long as nine years (Livingston-Bruce et al, 1994). For instance, people with a past history of panic disorder were over three times as likely to be dead nine years later compared with controls. The cause of this association is not yet clear, but there are clearly important public health implications of neurotic disorders in terms of both morbidity and mortality.
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