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Notes on Neurotic Disorders
Dr Ben Green
Suggested approach to topic:
Read the brief notes below, then see suggested references, before attempting the Self-Assessment Exercises at the end.
Brief Notes
- For scope of this collection of disorders please see ICD F 40 - F48
- Neurotic disorders represent relatively prevalent, persistent and damaging morbidity and so are not 'minor'. They represent a considerable direct and indirect cost to the country.
Panic Disorder (F41.0)
- Lifetime prevalence up to 6%, probably 3.5%
- 35% of college students report at least one panic in the last year (Norton et al, 1985)
- Onset late adolescence/twenties usually
- Women>men
- Episodic course over months or years
- May develop into agoraphobia
- Self medication with alcohol, nicotine, cannabis, street benzodiazepines may occur
- Runs in families
- Association with Mitral Valve Prolapse
- Differential should include PTSD, simple phobia, depression, MI, PE, Paroxysmal SVT, hyperthyroidism, episodic hypoglycaemia, phaeochromocytoma, carcinoid syndrome, caffeine or amphetamine use, alcohol or benzodiazepine withdrawal, TLE
Management
- Exclude organic causes
- Diazepam or other benzodiazepines (but bear in mind tolerance and dependence as always)
- SSRIs such as paroxetine 20 - 40 mg daily
- Tricyclics and MAOIs have been used historically too e.g. imipramine
- Beta blockers less useful than drugs above
- Cognitive behavioural therapy
- Anxiety Management Groups
Agoraphobia (F40.0)
- Fear of the marketplace
- Fear of having a panic attack in a public place
- Onset 20s to 30s
- Avoidance worsens the disorder - patients won't go out
- Secondary gains from neighbours, partner, children
- Chronic course
- Accounts for 60% of phobias (Marks, 1987)
- 66% are women between 15 and 35
- Runs in families along the female line
Management
Desensitisation by CPN, friend, partner under an agreed behavioural programme
Specific or simple Phobia (F40.2)
- First described by Hippocrates
- Lifetime prevalence about 10%
- May or may not be a sensitising event e.g. dog attack
- Onset child/adolescence
- May be lifelong
- Associated with avoidance behaviour
- Phobia of having blood taken seems very familial - 68% of patients with it also had relatives with the condition
Management
Desensitisation Hierarchy / Graded Exposure associated with anxiety management
Modeling
Flooding (ethical?)
Social Phobia (F40.2)
- Lifetime prevalence 13%
- Fear of incompetence or appearing foolish in social situations
- "Performance anxiety"
- Associated with Avoidance and loneliness - anxiety reinforces behaviour, avoidance reinforces expectations of anxiety and so on
- Chronic copurse
- Associated with panic attacks
Management
- Beta blockers
- Paroxetine ('shyness drug')
- Fluoxetine, citalopram
- Graded exposure and coaching
- CBT
Obsessive Compulsive Disorder (F42)
- First full description by Sir Aubrey Lewis in 1935
- Lifetime prevalence 2%
- Intrusive thoughts, impulses, fears, doubts which are not wanted by the patient and are resisted
- Compulsions to touch, count, check, arrange things, do rituals.
- Attempts to resist compulsions lead to worsening anxiety
- May follow understandable precipitant e.g. patient with washing compulsion who was bullied and smeared with faeces in a playground
- Most patients have obsessions and compulsions, 25% have just obsessions and 5% only compulsions
- Magical thinking
- 5% also have Tourette's
- 25% have some tic
- Chronic course over years
- Concordance for dizygotic twins 47% and monozygotic is 88%
- Serotonergic dysfunction implicated
- Differential should include depression and schizophrenia
Management
- Fluoxetine
- Clomipramine
- Exposure and response prevention with anxiety management
- Risperidone
- Neurosurgery - only in severe cases Cingulotomy or anterior capsulotomy, stereotactic limbic leucotomy helped 84% of severe OCD
Post Traumatic Stress Disorder (F43.1)
- Onset any age
- Symptoms may appear immediately or be latent, need to last more than a month (otherwise adjustment disorder or acute stress reaction)
- Often undiagnosed
- Associated with alcohol mis-use(27%), substance mis-use (8%), failed careers and marriages
- Merges with depressive illness
- Recurrent dreams, intrusive images, avoidance of cues that remind patient, foreshortened life expectancy, poor concentration and irritability seem key features
- Course 6-24 months
- Occurs in about 20-30% RTA survivors, can occur in rape (57%) and torture victims, police, medical, ambulance and nursing staff after physical assaults (37%) or helping at crashes etc…
- Vulnerability factors - female sex, CSA, previous PTSD, intensity and severity of traumatic event
Management
- Counselling, although well intentioned, may make worse
- CBT, family therapy and couple therapy may prevent further deterioration in established cases
- SSRIs
- Desensitisation for avoidance behaviour e.g RTA survivors who won't drive
- Avoid use of benzodiazepines for any length of time
- (Abreaction, EMDR - no good evidence base)
Generalised anxiety disorder (F41.1)
- Adolescent onset
- Beware late life presentations - organic or depression?
- 'Free-floating anxiety'
- Chronic
Management
- Exclude organic causes in all; I have met patients who have been referred for years of psychological therapies by their GP who turned out to have chronic hyperthyroidism
- Antidepressants
- Diazepam and benzodiazepines (tolerance and dependence issues)
- Buspirone and beta-blockers infrequently of use
Somatisation Disorder (F45.0) (sometimes known as Briquet's syndrome)
- Mainly females
- Dramatically recounted symptoms in diverse systems
- Multiple physicians
- Patients not pleased or reassured to hear negative findings, type and frequency of investigations multiply as a result
- Families ruled by individual's perceived illness
- Chronic and lifelong course
- Personality disorder of borderline, histrionic or antisocial types may co-exist
- Not the same as Munchausen's, similar to hypochondriasis, different to 'simple' hysteria / conversion disorder
- May follow CSA
- Depression may underlie the presentation
Management
- Difficult - diagnoses of hysteria, somatisation, malingering can be pejorative at best and a death sentence at worst (if significant pathology is missed). Polysymptomatic and fluctuating illnesses e.g. SLE or MS may attract the 'everything is supratentorial' label.
- Avoid arguing with patients or emphatically reassuring them - a waste of energy and emotion, you will not budge them from their viewpoint
- Agree they have a problem but that you don't know all the answers, say you will try to help
- Rule out further investigations (if you can!)
- Try and get a shared goal e.g. rehabilitation to a certain point - give them a way out to save face
- Treat co-existent depression
- Look for links between symptoms/presentation and psychodynamics, but avoid pushing your interpretation onto patient - unless they come to own it they will not acknowledge it is true (even if it is!)
Conversion disorder ( F44.9)
- Certain signs or symptoms that are inconsistent with anatomy or pathophysiology e.g. 'hysterical' blindness but visual evoked potentials are normal, inability to walk, but all pathways and muscles normal ('astasia abasia' described by Freud, but pre-figured by Dostoevsky 20 years before!)
- May get patient out of unwanted circumstances that they can't easily get out of e.g. child in wheelchair who can't go to normal school (where he is being secretly abused)
- Onset adolescence
- May occur more in patients with poor knowledge of bodily systems/anatomy e.g. children
- Children often no underlying organic pathology, adults may have - so be careful
- May see conversion amnesia, conversion anaesthesia, conversion blindness, conversion ataxia, conversion dumbness, conversion epilepsy, conversion paralysis. Conversion paralysis in the most common form, followed by conversion aphonia
Management
- Similar principles to above
- Psychoanalysis of hysterical Viennese patients led Freud to his view of the mind
- Psychoanalysis not now the treatment of choice because it takes too long!
Suggested References and Reading
The MRCPsych Study Manual (2000) Green - Petroc Press Theories of Personality Sixthe Edition (1999) Schultz & Schultz - Brooks/Cole Handbook of Medical Psychiatry (1996) Moore & Jefferson - MosbySelf Assessment Section
Depersonalisation:
What was the surname of the man who developed Gestalt Therapy?
Panic attacks occur in:
Copyright - Ben Green 2000
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