Transcript Neurotic disorders - the Peninsula MRCPsych Course

Neurotic
Disorders
for
Psychiatric
trainees.
Dr Keith Gilhooly
ST5 Psychiatrist
General points.
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Lots of comorbidity in these disorders
especially with depression, other neuroses,
PD, and substance misuse
For useful prevelance data…..
ECA. Euroupean catchment area survey.
(Robins & Regier, 1991)
NCS. National Co morbidity study . US
http://www.hcp.med.harvard.edu/ncs/
See back of handout.
Licences.( Arbitary).
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If asked pharmacological treatment for
anxiety disorder if in doubt say “SSRI Eg.
PAROXETINE.” It is licensed for
– Social anxiety, GAD, Panic disorder, OCD,
PTSD
Sertraline OCD, PTSD
Fluoxetine OCD
Esitalopram GAD, OCD, Panic disorder
Don’t forget emphasise patient choice
Psychodynamic understanding
of anxiety disorders.
Focus on;
1.Intrapsychic conflicts.
2.Unconcious fantasies.
3. Defense mechanisms
4. Compromise function of symptoms.
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Freud
Freud 1926 identifies 2 types anxiety.
Signal and traumatic.
 Signal anxiety alerts ego to Id
impulses,and fantasies inconsistent
with super ego.
 If defenses put in place by super ego
ineffective get traumatic anxiety. (GAD,
Panic disorder)
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Compromise
formations
If defense mechanism immature ego
synthesises compromise between the
wish and the defense.
 Psychiatric symptoms as well as
dreams and further fantasies are
compromise formations.
 Pleasure principle. Symptoms less
distressing than underlying conflict.
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Neurosis as opposed to
perversion
Perversion- regress to earlier stage
psychosexual development and
hypertrophy of that drive.
 If this hypertrophied drive sufficiently
repressed then the individual
developed a neurosis.
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Phobias- theories
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Pavlovian (Classical/ associative)
conditioning. An association is formed
between the stimulus and feeling
threatened. Watson shock /furry
rabbit(1919)
Operant conditioning.Two factor theory.
Mowrer. Avoidance behavior that
strengthens the “negative reinforcer”
Phobias. Theories.
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Psychodynamic- displacement of anxiety
from an unacceptable object eg self
destructive impulses (Freud, Little Hans),
onto a more acceptable object.
Displacement projection and avoidance.
Learning theory- vicarious and direct
learning from others that a situation is
threatening.
Innate or prepared behaviours.
Phobias F 40
ICD 10 Diagnostic Common
factors and differences
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Phobias Seen in up to 15% of people
Characterised by– Subsection A. Certain Specific thing or
situations, not CURRENTLY dangerous.
 Fear
and or Avoidance of phobic stimulus
external to subject.
Subsection B (12
symptoms)
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4 Autonomic arousal
– Palpitations, sweating, shaking, dry
mouth.
4 Chest and abdo symptoms.
Diff breathing, choking, chest pain,
nausea.
4 Mental state symptoms.
Dizzy,derealisation, depersonalisation,
fear losing control, fear dying.
Phobias. Subsection B
cotd.
Need 2 of these for agorophobia and social phobia. For
specific phobias number not specified.
Sebsection B for social phobia additionally has,
blushing, shaking, fear of vomiting, and urgency/ fear of
micturition
Subsection B also used in Dx GAD. Need 4 of them.
Subsection B also used in panic disorder and suggested that
all subsection B symptoms characteristic.
Section C and D.
– C Significant emotional distress. Insight
“Excessive and unreasonable”
– Symptoms in situation or in anticipation of
it.
– Panic disorder can be secondary
diagnosis to phobia and can indicate
severity.
Agorophobia F40.0
With above criteria(SectionA) specific
fear or avoidance must be of at least
2 of the following.
 Crowds
 public spaces
 travelling alone
 travel away from home.
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Agorophobia Stats
Lifetime prevelence 2-6% across
studies.
 6 month prevelence 2.5-5.8% ECA
 M:F 1:3
 Bimodal. Two peaks. 1. early-mid 20’s.
 2.Mid thirties.
 Therefore later than other phobias.
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Agorophobia treatment
SSRI first choice.
 Start low but can aim high. Eg
paroxetine at least 40mg, can go to
60 mg.(same as panic disorder)
 Clomipramine/Imipramine second
line (unlicensed)
 MAOI or augment with Lithium.
 Mood stabiliser
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Social Phobias F40.1
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Fear or avoidance
specifically of
– Focus of attention.
– Potentially
embarrassing or social
situations
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May be specific eg
eating, vomiting, pub
speaking.
Stats
Lifetime prevalence 2.4-13.3%
 12 month prevelence 7.9%
 M=F presenting for help.
 Comm survey M>F.
 Peak 5 yrs and 11-15 yrs.
 MZ/DZ 24.4%:15.3%???genetic
predisposition to interpret things as
dangerous.
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Social phobia.
Teatment
As usual CBT. Could be group setting.
 Social skills training.
 Modelling and graded exposure.
 SSRI/ . Evidence for paroxetine,
fluvoxamine and sertraline and
MAOI.
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Social phobia.
Treatment
Paroxetine and escitalopram licensed.
Response rates up to 90% with combined
approaches.
B-blockers. Only evidence that they help with
short term control of tremor and palpitations
Simple Phobias
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Phobia associated with single stimulus eg
spiders, flying etc
Lifetime prevelence 11.3%
Onset usually childhood with M=F
As adults is F>M (3:1-20:1)
Mean onset 15 years. Animal phobias 7
years
Childhood- usually environmental eg
animals
Adult- usually situational eg places
Treatment.CBT
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Systemic desensitisation. Graded exposure
Reciprocal inhibition. Relaxation (Wolpe)
Modelling
Avoidance is safety behaviour that results in
negative re enforcement.
Cognitive distortions related to negative re
enforcement. “If I am anxious it must be
dangerous”
Treatments CBT
Modelling
 Implosion
 Flooding no better than graded
exposure.
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Psychodynamic. ??? What conflict
symptoms represent. Repressed
impulses brought to counciousness.
Little Hans (Freud)
 Medications-generally not used
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Some unusual Phobias
Pogonophobia
-Beards
 Bogyphobia
-Bogeyman
 Panophobia
-Everything
 Syngenesophobia -Relatives
 ??Hippopotomonstrosesquippedali
ophobia.
-Long words
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Phobic Disorders..
Phobia
% of
phobias
F:M
Age of
onset
Agora
60%
2-3:1
15-35
Social
8%
Simple
17%
1:1
13-20
presenting
for help
3-20:1
Childhood
Illness
15%
F=M
?
OCD
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F=M
20
Panic Disorder
4 non-situational panic attacks over
4/52
 May be ‘non-fear’ in 10% ie don’t
describe feeling fearful.
 Descrete, abrupt, reaches max after a
few minutes.
 Same list autonomic, chest, and
mental state symptoms.
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Panic Disorder Stats.
Lifetime prevelence 4.2% (ECA, NCS)
 M:F 1:2-3
 Peaks 15-24, 45-54.
 Co morbidity with agorophobia 75%
Psyche clinic.
 In ICD 10 primary diagnosis would be
agorophobie. In DSM, other way round
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Panic Disorder
Probably imbalance of NA:5HT in
caudate nucleus
 May be linked to childhood respiratory
disorders (suffocation alarm)
 Highly comorbid (depression (50%),
ETOH (40%), OCD, phobias,
somatisation)
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Panic Disorder
treatment.
NICE Guidelines 2004.Patient
choice.Restricted Meds and or CBT
 SSRI first choice.
Clomipramine/Imipramine second
line (unlicensed,70-80% effective)
 Start low but can aim high. Eg
paroxetine can go to 60 mg.
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CBT.
Teach about body responses?
Thinking errors about dying.
 Relaxation techniques
 Control hyperventilation
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Generalised Anxiety
Disorder F41.1
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A. Non situational anxiety on
most days for 6 months.
Need 4 symptoms from
subsection B. One of these
must be from autonomic
arousal section.
Subsection B for GAD has
added general and non
specific symptoms also.
Lifetime prevelence (NCS)3-4%
 F:M 2:1
 Mean onset 21.(Range 2-60 yrs)
 50% also depressed
 Only 1/3 seek help
 Genetic heritability 30%
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Neurobiology
Loss regulatory control HPA axis.
 Dex sup test reduced cortisol
supression.
 Decrease GABA
 Dysregulation 5-HT system.
 Sustained activation stria terminalis
after prolonged CRF. Increase startle
response.
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Cognitive model (Dugas
2004)
Belief that worry keeps you safe
(Prepared)
 Cannot tolerate uncertainty.
 Search for perfect solutions leads to
failure and further worry.
 ?? Worry inhibits emotional processing
that is more distressing
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GAD adults report “”reverse parenting”
Unpredictability of outcomes
Cold, over controling parents.
Sensitised to needs of others. (To stay safe
in childhood)
Child learns to inhibit own emotional
experience and rely on anticipatory problem
solving
Rank high on empathy and worry about
interpersonal issues
Treatment.
NICE patient choice.
 Some evidence that CBT works.
 SSRI. Paroxetine licenced.Same
titration as for depression (BNF)
 Venlafaxine 75 mg od. Discontinue if
no response after 12 weeks.
 Imipramine and clomipramine
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Obsessive Compulsive
Disorder
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Recurrent, intrusive, unpleasant thought,
feelings, images or impulses (obsessions)
+/- compulsive behaviours (aim at reducing
anxiety)
Must be senseless to patient, resisted,
internal, and under own control ie not
imposed from external source.
Most common obsessions are
contamination and doubts
Most common compulsions are checking
and cleaning
OCD
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Affects 2-3%
Onset in 20s
F=M
Often comorbid with 2/3 depressed and ¼
socially phobic
Often delay 5-10 years before seeking help
Shopping, gambling, eating not OCD as
behaviour is ego-syntonic ie pleasant
OCD
Worse outcome if early onset, bizarre
obsessions, overvalued ideas and
always yield to the compulsion
 Treat with CBT- exposure to stimulus
with response prevention, loop tapes.
 Medication- SSRIs, clomipramine
 Best is combination- meds + CBT.
 Psychosurgery in extreme cases
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Psychodynamic Theory
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Similar to phobias. Id impulses and
fantasies in conflict with excessive super
ego.
Defense of magical undoing in compulsions
to make reparation for phantasised
destructiveness.
Intellectualisation leads to pre occupation
and and thus avoidance of conflict.
Therapy. Deal with issues of control. Loosen
excessive super-ego.
CBT
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(Salkovskis). Intrusive thoughts normal.
Those with OCD have increased sense of
responsibility and self blaming belief
systems (Core assumptions) that trigger
secondary NAT’s.
CA may be “Only immoral people have such
thoughts”
Exaggerated sense of responsibility.
Rather than dismiss thought end up
ritualising to undo.
Thought =Action
 Failing to prevent harm= causing
harm.
 No attenuation of concern by low
probability
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Adjustment Disorders
Maladaptive response to a stressor
that interferes with functioning
 Includes bereavement and adjustment
to medical disorders eg occurs in 5%
after medical admission
 F:M 2:1, any age
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Acute Stress Reaction
Occurs following exceptional stress
 Lasts hours to days
 May involve anger, depression and
withdrawal.
 Resolves on removing the stressor
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Post Traumatic Stress
Disorder
Affects 1-5% (more subclinical)
 Event is perceived as life threatening
often with helplessness
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Involves– Reliving the event
– Avoiding things associated with the event
– Increased arousal eg anxiety
– Numbing of response eg anhedonia
PTSD
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Aetiology- ‘Cognitive processing model’lack of processing due to being
overwhelmed by the emotional value of the
event (level of processing theory)
Treat with CBT and meds (SSRIs).
Also eye movement desensitisation and
reprogramming (EMDR therapy),
hypnotherapy and analytical psychotherapy.
Somatoform Disorders
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Characterised by physical
symptoms persisting
despite negative findings
Somatisation disorder
(Briquets syndrome)multiple, variable sx in
different systems for >2
years. Uncommon (0,10,2%) with F:M 20:1.
Onset in teens to 20s
High comorbidity
Somatoform Disorders
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Hypochondriacal
disorder- focus is that
mild symptoms indicate
serious disease
Includes body
dysmorphic disorder
Affects 5% with F=M,
onset 20-30s
80% also
depressed/anxious.
Dissociative/
Conversion Disorders
Loss of integration of memories,
control of body and identity with a
psychological cause (previously called
hysterical reaction)
 Allow a patient to avoid direct
expression of distress- ie distress is
expressed as physical symptom
 Up to 20% have histrionic PD
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Dissociative Disorders
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Dissociative disorders of movement and
sensation of psychological cause- usually
accompanied by ‘belle indifference’ (a
seeming to not care about the symptoms).
Dissociative amnesia- patchy loss of
memory for unpleasant events
Dissociative fugue- amnesia with a
purposeful journey away from home with
maintained self care
Dissociative Disorders
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Underlying physical cause
found in 1-2/3 (be cautious
not to miss!)
F:M 2-5:1 often with Fhx.
Onset as young adult
Rural>urban (odd) and low
SE class
90% resolve in 1/12
Depersonalisation/
derealisation
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A subjective ‘as if’ phenomena that things
are remote, unreal and automatised with
intact insight
Often fleeting and may be normal
May decrease anxiety but is unpleasant
Usually part of another disorder eg anxiety
or depression
F:M 2:1