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Neurotic Disorders
Neurotic Disorders
Department of Psychiatry
1st Faculty of Medicine
Charles University, Prague
Head: Prof. MUDr. Jiří Raboch, DrSc.
Neurotic Disorders
Neurotic, stress-related, and somatoform
disorders have common historical origin with the
concept of neurosis and association of a
substantial proportion of these disorders with
psychological causation.
Mixtures of symptoms, especially anxiety and
depressive ones are common in these disorders
About one fourth of the population in developed
countries will suffer from neurotic disorders
during its lifetime course.
With the exception of social phobia their
frequency is higher in women than in men.
Neurotic, Stress-Related and
Somatoform Disorders (F40-F48)
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive-compulsive disorder
F43 Reaction to severe stress, and
adjustment disorders
F44 Dissociative [conversion]
disorders
F45 Somatoform disorders
F48 Other neurotic disorders
F40 Phobic anxiety disorders
F40 Phobic anxiety disorders
F40.0 Agoraphobia
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder,
unspecified
Phobic Anxiety Disorders
In agoraphobia, social and specific phobias, anxiety
is evoked predominantly by certain well-defined
situations or objects, which are external to the
individual and are not currently dangerous.
As a result, these situations or objects are
characteristically avoided or endured with dread.
Phobic anxiety fluctuates from mild uneasy to
terror. 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.
The anxiety is not relieved by the knowledge that
other people do not regard the situation in question
as dangerous or threatening.
Agoraphobia
„Agoraphobia“ - the fear from marketplace.
Agoraphobia includes various phobias embracing fears
of leaving home: fears of entering shops, crowds, and
public places, or of traveling alone in trains, buses,
underground or planes.
The lack of an immediately available exit is one of the
key features of many agoraphobic situations.
The avoidance behaviour causes sometimes that the
sufferer becomes completely housebound.
Most sufferers are women. Onset - early adult life.
The lifetime prevalence - between 5—7%.
High co-morbidity with panic disorder; depressive and
obsessional symptoms and social phobias may be also
present.
Agoraphobia
Anticipative Fobic
Anxiety Anxiety
Specific Situation
Social Phobias
Clinical picture - fear of scrutiny by other people in
comparatively small groups leading to avoidance of
social situations
The fears may be
• discrete - restricted to eating in public, to be introduced to
other people, to public speaking, or to encounters with the
opposite sex
• diffuse - social situations outside the family circle.
Direct eye-to-eye confrontation may be stressful.
Low self-esteem and fear of criticism.
Symptoms may progress to panic attacks.
Avoidance - almost complete social isolation.
Usually start in childhood or adolescence.
Estimation of lifetime prevalence - between 10-13 %.
It is equally common in both sexes.
Secondary alcoholism.
Social Phobias
Anticipative
Fobic
Anxiety
Anxiety
Social Stress
Specific (Isolated) Phobias
1. Fears of proximity to particular animals
• spiders (arachnophobia)
• insects (entomophobia)
• snakes (ophidiophobia)
2. Fears of specific situations such as
• heights (acrophobia)
• thunder (keraunophobia)
• darkness (nyctophobia)
• closed spaces (claustrophobia)
3. Fears of diseases, injuries or medical examinations
• visiting a dentist
• the sight of blood (hemophobia) or injury (pain —
odynophobia)
• the fear of exposure to venereal diseases (syphilidophobia)
or AIDS-phobia.
Usually arise in childhood or early adult life and can
persist for decades if they remain untreated.
Lifetime prevalence - between 10-20%.
F41 Other Anxiety Disorders
F41 Other anxiety disorders
F41.0 Panic disorder (episodic
paroxysmal anxiety)
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive
disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
Other Anxiety Disorders
Manifestations of anxiety are also the
major symptoms of these disorders,
however, it is not restricted to any
particular environmental situation.
Panic Disorder
The essential features are recurrent attacks of severe anxiety
(panic attacks) which are not restricted to any particular
situation or set of circumstances.
Typical symptoms are palpitations, chest pain, choking
sensations, dizziness, and feelings of unreality
(depersonalisation or derealization).
Individual attacks usually last for minutes only. The frequency
of attacks varies substantially.
Frequent and predictable panic attacks produce fear of being
alone or going into public places.
The afflicted persons used to think that they got a serious
somatic disease.
The course of panic disorder is long-lasting and is complicated
with various comorbidities, in half of the cases with
agoraphobia.
The estimation of lifetime prevalence moves between 1-3%.
Panic Disorder
Panic Anticipative
Attac Anxiety
General Anxiety Disorder
The essential feature is anxiety lasting more than 6 months,
which is generalized and persistent but not restricted to, or
even strongly predominating in, any particular environmental
circumstances.
Symptoms: continuous feelings of nervousness, trembling,
muscular tension, sweating, lightheadedness, palpitations,
dizziness, and epigastric discomfort.
Fears that the patient or a relative will shortly become ill or
have an accident are often expressed, together with a variety
of other worries and forebodings.
The estimation of lifetime prevalence moves between 4-6 %.
This disorder is more common in women, and often related to
chronic environmental stress.
Its course uses to be fluctuating and chronic connected with
symptoms of frustration, sadness and complicated with abuse
of alcohol and other illicit drugs.
Mixed Anxiety and Depressive
Disorder
Symptoms of both anxiety and depression
are present, but neither of symptoms,
considered separately, is sufficiently
severe to justify a diagnosis of depressive
episode or specific anxiety disorder.
Some autonomic symptoms, such as
tremor, palpitations, dry mouth, stomach
churning, must be present.
Individuals with this mixture of
comparatively mild symptoms are
frequently seen in primary care.
Etiology of Anxiety Disorders
The etiology of anxiety disorders is not exactly
known.
Genetic factors were found to play a role.
Nongenetic factors, such as various stressful life
events during early or later stages of ontogenesis
were thought to be even more important.
Several different neurotransmitter systems have
been implicated in these disorders, including the
noradrenergic, GABA, and serotoninergic systems
in some parts of the brain.
The role of CO2 in the etiology of panic disorder is
seriously discussed.
Clinical Management of Anxiety
Disorders
Treatment of anxiety disorders:
• various psychotherapeutic techniques
cognitive-behavioural therapy (CBT)
psychodynamic approaches
• psychopharmacotherapy
benzodiazepines (alprazolam, clonazepam) - for several weeks
(potential for abuse, development of tolerance and addiction)
Buspirone - little abusive potential; especially GAD, not effective in
panic disorder; longer use is necessary
beta-blocking drugs - for the short treatment of performance
anxiety, especially somatic symptoms like tremor
antihistaminics
various types of antidepressants - SRIs (clomipramine, citalopram,
fluoxetine, fluvoxamine, paroxetitle, sertraline), MOAIs
(tranylcypromifle), RIMA (moclobemide) and SNRI (venlafaxine);
well tolerated, no abuse potential
Recommendation: to start the treatment with a brief
course of benzodiazepines as well as with
antidepressants for a longer period and to combine the
drug treatment with various types of psychotherapy.
Commonly Used Anxiolytics
Drug Commonly used Elimination halftime
dosage (mg) (hours)
Alprazolam 0,5-6 12-15
Bromazepam 3-15 12
Diazepam 5-30 24-72
Chfordiazepoxied 10-50 24-100
Clobazam 20-30 20
Clonazepam 1-8 34
Clorazepate 15-60 60
Lorazepam 1-4 11-13
Medazepam 10-30 29
Oxazepam 30-90 4-20
Tofizopam 50-300 6
Buspirone 20-30 2-11
Hydroxyzine 300-400 12-20
F42 Obsessive-Compulsive
Disorder (OCD)
F42 Obsessive-compulsive disorder
F42.0 Predominantly obsessional
thoughts or ruminations
F42.1 Predominantly compulsive acts
(obsessional rituals)
F42.2 Mixed obsessional thoughts and
acts
F42.8 Other obsessive-compulsive
disorders
F42.9 Obsessive-compulsive disorder,
unspecified
Obsessive-Compulsive Disorder
(OCD)
Obsessional thought are ideas, images or impulses that enter
the individual’s mind again and again in a stereotyped form.
They are recognized as the individual’s own thoughts, even
though they are involuntary and often repugnant. Common
obsessions include fears of contamination, of harming other
persons or sinning against God.
Compulsions are repetitive, purposeful, and intentional
behaviours or mental acts performed in response to obsessions
or according to certain rule that must be applied rigidly.
Compulsions are meant to neutralize or reduce discomfort or to
prevent a dreaded event or situation.
Autonomic anxiety symptoms are often present.
There is very frequent comorbidity with depression (about
80%) - suicidal thoughts. Obsessive-compulsory symptoms
may appear in early stages of schizophrenia.
The life time prevalence: 2 - 3%. Equally common in men and
women. The course is variable and more likely to be chronic.
Etiology of OCD
The neurobiological model has received widespread
support in the past decade. OCD occurs more often
in persons who have various neurological disorders,
including cases of head trauma, epilepsy,
Sydenham’s and Huntington’s chorea. OCD has also
been linked to birth injury, abnormal EEG findings,
abnormal auditory evoked potentials, growth delays,
and abnormalities in neuropsychological test results.
Recently, a type of OCD has been identified in
children after a group A beta-streptococcal infection.
The most widely studied biochemical model has
focused on the neurotransmitter serotonin because
SRIs are effective in treating patients with OCD.
Brain imaging studies have provided some evidence
of basal ganglia involvement in persons with OCD.
Clinical Management
The treatment of OCD has traditionally been viewed
as difficult and unsatisfactory. Recent developments
have changed this picture substantially.
Pharmacotherapy
• antidepressants influencing the central serotoninergic
system (clomipramine and SSRIs); higher doses of the
drugs are required to treat OCD than depression, and
response is often delayed.
Cognitive-behaviour therapy
Family therapy
Patient support groups
Psychosurgery (e.g. stereotactic cingulotomy)
Epidemiology
30 28,7
The Lifetime Prevalence
25
20
(%)
15 13,3
11,3
10
7,6
5,3 5,1
5 3,5
0
All Anxiety Social Specific PTSD Agorafobia GAD Panic
Disorders Phobias Phobias without Disorders
Panic
The onset follows the trauma with a latency period, which may
range from several weeks to months, but rarely more than half
a year.
The lifetime prevalence is estimated at about 0.5% in men and
1.2% in women.
Post-traumatic Stress Disorder
(PTSD)
Acute Flashback
Reaction
on Trauma
Trauma
Clinical Management
Pharmacological approach:
• antidepressant medication
• short-term benzodiazepines trials
• mood stabilizers (carbamazepine, valproate)
• antipsychotics
Psychotherapy is also of importance - CBT
using education and exposure techniques
Group therapy, family therapy and self-
help groups are widely recommended.
Adjustment Disorders
Adjustment disorder comprises states of subjective distress
and emotional disturbance arising in the period of adaptation
to a significant life change or to the consequences of a
stressful life event, such as serious physical illness,
bereavement or separation, migration or refugee status.
The clinical picture: depressed mood, anxiety, worry, a feeling
of inability to cope, plan ahead, or continue in the present
situation, and some degress of disability in the performance of
daily routine.
Onset - within 1 month; duration - below 6 months.
More frequently women, unmarried and young persons.