F40 – F48 NEUROTIC, STRESS-RELATED AND SOMATOFORM DISORDERS

F40 PHOBIC ANXIETY DISORDERS

Anxiety is evoked only, or predominantly, by certain well-defined situations or objects (external to
the individual) which are not currently dangerous. The individual's concern may focus on individual
symptoms such as palpitations or feeling faint and is often associated with secondary fears of dying,
losing control, or going mad.

Fear relating to the presence of disease (nosophobia) and disfigurement (dysmorphobia) are
classified under hypochondriasis. However, if the fear of disease arises predominantly and
repeatedly from possible exposure to infection or contamination, or is simply a fear of medical
procedures (injections, operations, etc.) or medical establishments (dentists' surgeries, hospitals,
etc.), a category from specific phobia will be appropriate

Phobic anxiety often coexists with depression

F40.0 AGORAPHOBIA

Agoraphobia refers to a fear of or anxiety regarding places from which escape might be difficult. It
can be the most disabling of the phobias because it can significantly interfere with a person’s ability
to function in work and social situations outside the home.

Clinical features:

Fears of open spaces, presence of crowds and the difficulty of immediate easy escape to a safe place
(usually home), fears of leaving home: fear of entering shops, crowds, and public places, or of
travelling alone in trains, buses, or planes.

Most sufferers are women and the onset is usually early in adult life.

Diagnostic guidelines:

a. The psychological or autonomic symptoms must be primarily manifestations of anxiety and not
secondary to other symptoms, such as delusions or obsessional thoughts
b. Anxiety must be restricted to (or occur mainly in) at least two:
i. crowds, public places, travelling away from home, and travelling alone
c. Avoidance of the phobic situation must be, or have been, a prominent feature

F40.1 SOCIAL PHOBIAS

Social phobias often start in adolescence and are centred around a fear of scrutiny by other people in
comparatively small groups (as opposed to crowds), usually leading to avoidance of social situations.
Clinical features:

They may be discrete (i.e. restricted to eating in public, to public speaking, or to encounters with the
opposite sex) or diffuse, involving almost all social situations outside the family circle.

A fear of vomiting in public may be important.

Direct eye-to-eye confrontation may be particularly stressful in some cultures.

Social phobias are usually associated with low self-esteem and fear of criticism.

Diagnostic guidelines:

a. The psychological, behavioural, or autonomic symptoms must be primarily manifestations of

anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
b. The anxiety must be restricted to or predominate in particular social situations
c. The phobic situation is avoided whenever possible.

F40.2 SPECIFIC (ISOLATED) PHOBIAS

The diagnosis of specific phobia requires the development of intense anxiety, even to the point of
panic, when exposed to the feared object. Persons with specific phobias may anticipate harm, such
as being bitten by a dog, or may panic at the thought of losing control; for instance, if they fear being
in an elevator, they may also worry about fainting after the door closes.

Clinical features:

triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobias.

arise in childhood or early adult life and can persist for decades if they remain untreated.

Diagnostic guidelines:

a. The psychological or autonomic symptoms must be primary manifestations of anxiety, and not
secondary to other symptoms such as delusion or obsessional thought
b. The anxiety must be restricted to the presence of the particular phobic object or situation
c. The phobic situation is avoided whenever possible.

ETIOLOGY

Behavioral factors:

Operant conditioning theory provides a model to explain this phenomenon: Anxiety is a drive that
motivates the organism to do whatever it can to obviate a painful aPect. In the course of its random
behavior, the organism learns that certain actions enable it to avoid the anxiety-provoking stimulus.
These avoidance patterns remain stable for long periods as a result of the reinforcement they receive
from their capacity to diminish anxiety. This model is readily applicable to phobias in that avoidance
of the anxiety-provoking object or situation plays a central part.

Psychoanalytic factors:

Freud hypothesized that the major function of anxiety is to signal the ego that a forbidden
unconscious drive is pushing for conscious expression and to alert the ego to strengthen and marshal
its defenses against the threatening instinctual force. Freud viewed the phobia—anxiety hysteria, as
he continued to call it—as a result of conflicts centered on an unresolved childhood oedipal
situation.
Anxiety that is characteristically a fear of castration. When repression fails to be entirely successful,
the ego must call on auxiliary defenses. In patients with phobias, the primary defense involved is
displacement; that is, the sexual conflict is displaced from the person who evokes the conflict to a
seemingly unimportant, irrelevant object or situation, which then has the power to arouse a
constellation of affects, one of which is called signal anxiety.

TREATMENT

Pharmacotherapy

Benzodiazepines. – alprazolam, lorazepam – most prescribed – clonazepam; The major reservations

among clinicians regarding the use of benzodiazepines are the potential for dependence, cognitive
impairment, and abuse, particularly with long-term use.

SSRIs - Help reduce or prevent relapse from various forms of anxiety, including agoraphobia. The
main advantages of SSRIs antidepressants include their improved safety profile in overdose and more
tolerable side-effect burden. Common side effects of most SSRIs are sleep disturbance, drowsiness,
lightheadedness, nausea, and diarrhea; many of these adverse effects improve with continued use.
Another commonly reported side effect of SSRIs is sexual dysfunction.

Tricyclic and Tetracyclic Drugs – tricyclic drugs clomipramine (Anafranil) and imipramine (Tofranil) are
the most effective in the treatment of these disorders. Dosages must be titrated slowly upward to
avoid overstimulation

Psychotherapy

Supportive – use of psychodynamic concepts, adaptive coping, reality testing, advice regarding
behaviour

Insight-oriented – goal is to increase the patient’s development of insight into psychological conflicts
that, if unresolved, can manifest as symptomatic behavior.

Behavioural therapy - Techniques include positive and negative reinforcement, systematic

desensitization, flooding, implosion, graded exposure, response prevention, stop thought, relaxation
techniques, panic control therapy, self-monitoring, and hypnosis

Cognitive therapy - the premise that maladaptive behavior is secondary to distortions in how people
perceive themselves and in how other perceive them. Treatment is short term and interactive, with
assigned homework and tasks to be performed between sessions that focus on correcting distorted
assumptions and cognitions.

Virtual therapy - Computer programs have been developed that allow patients to see themselves as
avatars who are then placed in open or crowded spaces.

F41 OTHER ANXIETY DISORDERS

F41.0 PANIC DISORDER [episodic paroxysmal anxiety]

An acute intense attack of anxiety accompanied by feelings of impending doom is known as panic
disorder. The anxiety is characterized by discrete periods of intense fear that can vary from several
attacks during one day to only a few attacks during a year. Patients with panic disorder present with a
number of comorbid conditions, most commonly agoraphobia, which refers to a fear of or anxiety
regarding places from which escape might be difficult.
Clinical features:

recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set
of circumstances, and which are therefore unpredictable.

As in other anxiety disorders, the dominant symptoms vary from person to person, but sudden onset
of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization
or derealization) are common.

secondary fear of dying, losing control, or going mad. Individual attacks usually last for minutes only,
though sometimes longer; their frequency and the course of the disorder are both rather variable.

For a definite diagnosis, several severe attacks of autonomic anxiety should have occurred within a
period of about 1 month:

a. In circumstances where there is no objective danger

b. Without being confined to known or predictable situations
c. With comparative freedom from anxiety symptoms between attacks (although anticipatory
anxiety is common).

ETIOLOGY

Biological factors - related to a range of biological abnormalities in brain structure and function;
abnormal regulation of brain noradrenergic systems is also involved in the pathophysiology of panic
disorder; peripheral and central nervous system (CNS) dysregulation in the pathophysiology of panic
disorder; The major neurotransmitter systems that have been implicated are those for
norepinephrine, serotonin, and GABA. Serotonergic dysfunction is quite evident in panic disorder;
The biological data have led to a focus on the brainstem, the limbic system, and the prefrontal cortex;
MRI, in patients with panic disorder have implicated pathological involvement in the temporal lobes,
particularly the hippocampus and the amygdala; dysregulation of cerebral blood flow.

Genetic factors - Orst-degree relatives of patients with panic disorder have a four- to eightfold higher
risk for panic disorder than first-degree relatives of other psychiatric patients; monozygotic twins are
more likely to be concordant for panic disorder than are dizygotic twins.

Psychosocial factors - Psychoanalytic theories conceptualize panic attacks as arising from an

unsuccessful defense against anxiety-provoking impulses. What was previously a mild signal anxiety
becomes an overwhelming feeling of apprehension, complete with somatic symptoms; higher
incidence of stressful life events, etiological factor in adult female patients appears to be childhood
physical and sexual abuse.

F41.1 GENERALIZED ANXIETY DISORDER (GAAM)

Anxiety can be conceptualized as a normal and adaptive response to threat that prepares the
organism for flight or fight. Persons who seem to be anxious about almost everything, however, are
likely to be classified as having generalized anxiety disorder. Generalized anxiety disorder is defined
as excessive anxiety and worry about several events or activities for most days during at least a 6-
month period.

Clinical features:

"free-floating" - which is generalized and persistent but not restricted to, or even strongly
predominating in, any particular environmental circumstances
continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness,
palpitations, dizziness, and epigastric discomfort are common.

more common in women, and often related to chronic environmental stress. Its course is variable but
tends to be fluctuating and chronic.

Diagnostic guidelines:

The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time,
and usually for several months. These symptoms should usually involve elements of:

a. apprehension (worries about future misfortunes, feeling "on edge", difficulty in concentrating,
etc.)
b. motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
c. autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric
discomfort, dizziness, dry mouth, etc.)

ETIOLOGY

As currently defined, generalized anxiety disorder probably affects a heterogeneous group of

persons.

Biological factors - brain areas hypothesized to be involved in generalized anxiety disorder are the
basal ganglia, the limbic system, and the frontal cortex; lower metabolic rate in basal ganglia and
white matter in patients with generalized anxiety disorder than in normal control subjects; A variety
of electroencephalogram (EEG) abnormalities has been noted in alpha rhythm and evoked
potentials.

Psychosocial factors - two major schools of thought about psychosocial factors leading to the
development of generalized anxiety disorder are the cognitive-behavioural school and the
psychoanalytic school. According to the cognitive-behavioral school, patients with generalized
anxiety disorder respond to incorrectly and inaccurately perceived dangers. The inaccuracy is
generated by selective attention to negative details in the environment, by distortions in information
processing, and by an overly negative view of the person’s own ability to cope. psychoanalytic school
hypothesizes that anxiety is a symptom of unresolved, unconscious conflicts.

Treatment

Psychotherapy - The major psychotherapeutic approaches to generalized anxiety disorder are

cognitive-behavioral, supportive, and insight oriented. Cognitive approaches address patients’
hypothesized cognitive distortions directly, and behavioral approaches address somatic symptoms
directly. The major techniques used in behavioral approaches are relaxation and biofeedback.
Supportive therapy offers patients reassurance and comfort, although its long-term efficiacy is
doubtful. Insight-oriented psychotherapy focuses on uncovering unconscious conflicts and identifying
ego strengths.

Pharmacotherapy - Benzodiazepines have been the drugs of choice for generalized anxiety disorder.
They can be prescribed on an as needed basis, so that patients take a rapidly acting benzodiazepine
when they feel particularly anxious. e SSRIs sertraline (Zoloft), citalopram (Celexa), or paroxetine
(Paxil) are better choices in patients with high anxiety disorder
F42 OBSESSIVE – COMPULSIVE DISORDER

Obsessive-compulsive disorder (OCD) is represented by a diverse group of symptoms that include

intrusive thoughts, rituals, preoccupations, and compulsions. These recurrent obsessions or
compulsions cause severe distress to the person. The obsessions or compulsions are timeconsuming
and interfere significantly with the person’s normal routine, occupational functioning, usual social
activities, or relationships. A patient with OCD may have an obsession, a compulsion, or both.

An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. In contrast to an

obsession, which is a mental event, a compulsion is a behavior.

Clinical features:

Obsessional thoughts are ideas, images or impulses that enter the individual's mind again and again
in a stereotyped form.

recognized as the individual's own thoughts, even though they are involuntary and often repugnant.

Compulsive acts or rituals are stereotyped behaviours that are repeated again and again.

Diagnostic guideline:

For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most
days for at least 2 successive weeks and be a source of distress or interference with activities.

The obsessional symptoms should have the following characteristics

a. they must be recognized as the individual's own thoughts or impulses

b. there must be at least one thought or act that is still resisted unsuccessfully, even though others
may be present which the sufferer no longer resists
c. the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or
anxiety is not regarded as pleasure in this sense)
d. the thoughts, images, or impulses must be unpleasantly repetitive.

ETIOLOGY (SORRY BASIN SO OCCUPIED)

Biological factors – neurotransmitters: dysregulation of serotonin is involved in the symptom

formation of obsessions and compulsions in the disorder, serotonergic drugs are more effective in
treating OCD than drugs that affect other neurotransmitter systems, altered function in the
neurocircuitry between orbitofrontal cortex, caudate, and thalamus, (PET)—have shown increased
activity (e.g., metabolism and blood flow) in the frontal lobes, the basal ganglia (especially the
caudate), and the cingulum, Relatives of probands with OCD consistently have a threefold to fivefold
higher probability of having OCD or obsessive-compulsive features than families of control probands.
Behavioural factors - According to learning theorists, obsessions are conditioned stimuli. A relatively
neutral stimulus becomes associated with fear or anxiety through a process of respondent
conditioning by being paired with events that are noxious or anxiety producing. Thus, previously
neutral objects and thoughts become conditioned stimuli capable of provoking anxiety or discomfort.

Psychosocial factors - OCD differs from obsessive-compulsive personality disorder, which is

associated with an obsessive concern for details, perfectionism, and other similar personality traits, ,
a male patient, whose mother stays home to take care of him, may unconsciously wish to hang on to
his OCD symptoms because they keep the attention of his mother – gaining symptomatology for
secondary gains. In classic psychoanalytic theory, OCD was termed obsessive-compulsive neurosis
and was considered a regression from the oedipal phase to the anal psychosexual phase of
development. Ambivalence is an important feature of normal children during the anal-sadistic
developmental phase; children feel both love and murderous hate toward the same object,
sometimes simultaneously. Patients with OCD often consciously experience both love and hate
toward an object. This conflict of opposing emotions is evident in a patient’s doing and undoing
patterns of behavior and in paralyzing doubt in the face of choices. Magical Thinking - in magical
thinking, regression uncovers early modes of thought rather than impulses; that is, ego functions as
well as id functions are affected by regression. Inherent in magical thinking is omnipotence of
thought. Persons believe that merely by thinking about an event in the external world they can cause
the event to occur without intermediate physical actions. This feeling causes them to fear having an
aggressive thought.

Symptom pattern – contamination, pathological doubt, intrusive thoughts, symmetry (can I please
stop)

Treatment

Pharmacotherapy - The efficacy of pharmacotherapy in OCD has been proved in many clinical trials
and is enhanced by the observation that the studies find a placebo response rate of only about 5
percent. SSRIs - Higher dosages have often been necessary for a beneficial effect, can cause sleep
disturbance, nausea and diarrhea, headache, anxiety, and restlessness, these adverse effects are
often transient, clomipramine is the most selective for serotonin reuptake versus norepinephrine
reuptake and is exceeded in this respect only by the SSRIs, significant sedation and anticholinergic
effects, including dry mouth and constipation.

Behavioural therapy - Desensitization, thought stopping, flooding, implosion therapy, and aversive
conditioning have also been used in patients with OCD. In behavior therapy, patients must be truly
committed to improvement.

Psychotherapy

Deep brain stimulation – indwelling electrodes in various basal ganglia nuclei.