Symptoms Psychosis Neurosis

Hallucinations + -

Delusions + -

Thought disorder + -

Reality testing Impaired Intact

Insight Impaired Retained

 Neurotic, stress-related and
somatoform disorders
Symptom or group of symptoms

Behaviour greatly effected but socially

acceptable

Insight and reality testing retained

Personality not disorganised

 Epidemiology
Prevalence Marriage
 Age group 25-44  Protective factor for males
 Life time 40%
 Mean number 2.1
Childhood behaviour &
 General practice 9%
neurosis
 Mixed anx & dep 80%  No relation with neurosis
Life events risk  Conduct disorder related to
antisocial personality dis
 Vulnerability factors
 Long term difficulties Mortality
 Provoking factor  Higher 1.5 times
Socioeconomic status  Risk of suicide & substance
 Lower social class & educational abuse
status Outcome after one year
 Urban areas  25% improve
 50% variable course
 25% deteriorate
 Generalised anxiety disorder
Disproportional to threat or more prolonged
Clinical features

Psychological Genitourinary
 Worrying thoughts • Frequency of micturition
 Fearful anticipation • Erectile difficulty
Neuromuscular
Tremor
Somatic (3) •
• Aches & pains
Gastrointestinal
• Dry mouth Sleep disturbances
• Difficulty swallowing • Early insomnia
Respiratory • Night terrors
• Hyperventilation Co morbidity (60%)
• Difficulty breathing
• Phobic or depressed
Cardiovascular
• Palpitations • Substance abuse
• Chest oppression
 Panic disorder
Recurrent attacks of severe anxiety not restricted to any situation

Biological basis
• Biochemical: Sodium lactate & carbon
dioxide induce attacks
• First degree relatives X 4 times
• ↑ bf right parahippocampal area
• Neurotransmitter abnormalities: NA,
5HT, GABA
Clinical features
Psychological:
• Overwhelming fear of dying/losing
control/going mad Co morbidity (90%)
Somatic: • Anxiety & depression
• Dyspnoea/chest oppression/dizziness
• Sweating/palpitation/flushing/trembling • Substance abuse
• Nausea/abdominal discomfort Prognosis
• 30% recover
• 50% recurrences, symptoms mild
• 20% chronic
 Agoraphobia
Multiple phobic symptoms with high levels of anxiety

Epidemiology Avoidance
Commonest phobic disorder
75% females • Crowds
Premorbid dependency traits • Public transport
50% have history of panic disorder
• Confinement
Clinical features • Cinemas/theatres
Fear
• Leaving home
Anticipatory anxiety
• Being alone
• Being trapped
Prognosis
Anxious thoughts
(fainting & losing control) • H/O panic disorder better
outcome

• Duration > 6 months

prolonged fluctuating course
 Obsessive compulsive disorder
Recurrent thoughts, impulses, or images despite efforts to exclude them
Prevalence 2%, slightly more common in females
Premorbid personality Compulsions (Obsessional rituals)
OCPD in one third • Checking
OCPD leads to depression more often • Washing
Thoughts • Restricted to one place in one third
• Intrude against will
• Recognised as own but senseless Anxiety & depression common
• Are resisted Organic basis
Content • Increased bf orbito frontal cortex
• Contamination • Small size caudate nucleus
• Pathological doubt • 5HT receptors supersensitive
• Symmetry
Associated with
• Sexual &Aggressive
• Encephalitis lethargica
Ruminations
• Repetitive inconclusive thoughts • Sydenham’s chorea
• “Meaning of life” • Tourette syndrome
Images • Brain trauma
• Inside head Secondary to
• Sexual, aggressive nature • Depression 30%
• Anorexia nervosa
• Somatoform disorders
 Anxiety disorders
Differential diagnosis Management
Generalised anxiety disorder Drugs
Physical illnesses Benzodiazepines Alprazolam 0.25mg BD
• Thyrotoxicosis SSRI’s Fluoxetine 20mg/D
• Phaeochromocytoma Tricyclic Antidepressants
• Hypoglycaemia Imipramine 150mg/D
Substance abuse Clomipramine 150mg/D
• Alcohol withdrawal MAOI’s Moclobemide 300mg/D
• Amphetamine & cocaine abuse B-Blockers Propanolol 20mg BD
• Excessive use of caffeine Azapirone Buspirone 5mg TDS
Phobic anxiety
• Ischaemic heart disease Behavior therapy
• Paranoid & psychotic states
• Desensitisation
• Post traumatic stress disorder
• Depression
• Relaxation therapy
• Personality disorders • Exposure & response prevention
(Avoidant, schizoid, & paranoid)
Cognitive psychotherapy
 Somatoform disorders

Physical symptoms Dissociative disorders

(Hysteria) Dissociative amnesia
Sudden onset
Females 10 times more, lower socio •
Circumscribed personal memory loss
educational background •
Dissociative fugue state
Stress related; physical symptom • Wandering in amnesic state
without corresponding pathology • Behaviour purposeful (new identity)
Symptoms: Dissociative stupor
Motionless for hours
• blindness, deafness, tunnel vision •
Muscle tone normal
•
• Aphonia, seizures, paralysis Exclude organicity, alcohol, or substance abuse,
Associated features epilepsy
• Primary & secondary gain
• La belle indifference
• identification

90% recover; 25% develop CNS

disease
 Somatoform disorders
(Types)

Somatisation disorder Hypochondriasis

• More common in females • Equally common both sexes
• 20% 1st degree relatives; F/H • No familial aggregation
antisocial personality disorder & • Preoccupation with having serious
alcoholism and progressive disease
• Multiple physical complaints • Common regions: head, neck,
abdomen
Chest/cardiac
• May have obsessional & phobic
Back/joint pains quality but no resistance or
Menstrual symptoms avoidance
• Mood swings/irritability • May be secondary to:
• Dramatic & inconsistent histories Depression
• Seek immediate relief Anxiety
• Extensively investigated & Psychosis
treated • Seek reassurance & investigations
• Runs chronic course
 Somatoform disorders
Aetiology Treatment
Psychoanalytic theory • Do not confront
• Conflict between threatening ideas
and impulses results in anxiety • Impossible to make distinction
which gets converted into between cons/uncons origin
symptoms (primary gain)
• Examine and investigate with
• Care & sympathy received minimum fuss
constitutes secondary gain
• Reassure
Sociological theory • Minimise secondary gains
• Sick role exempts from social
obligations
• Reward symptom-free periods
• Allow discard symptoms
• Illness behaviour is determined by
patient’s ethnic, cultural, and without losing self-esteem
educational background • Abreaction
 Defence mechanisms
Automatic psychological
measures Displacement: Transfer of affect,
Used universally & not limited to usually anger or fear, from one
psychiatric disorders person to another
Indicate both health & disease Rationalisation: Justifying
reasoning after the event
Undoing: Acts carried out to
Repression: Thoughts & feelings cancel out the previous act
unacceptable to consciousness
are thrust back into unconscious Regression: Reversal to earlier
modes of functioning
Denial: Automatic distortion of outer
reality Turning against the self: Deflection
Projection: Attribute disowned &
of hostile & disadvantageous
ascribed to somebody else behaviour towards self
Reaction formation: Developing Sublimation: Harmful urges given
opposite to the one being socially acceptable expression
defended against Compensation: Development of
abilities to conceal defect
Grief reaction
Abnormal grief
• More intense
• Onset delayed
• Lasting > 6 months
Risk factors
Sudden, horror deaths
Ambivalent, dependent relationships
Features
Denial
Pseudo hallucinations & illusions
Anxiety & depressive features
Identification symptoms
Treatment
Address deceased in past tense
Discuss last days before death
Visit grave
Symptomatic treatment for depression
 Stress related disorders
Stress
Acute stress reaction
Stress: Overwhelming threat
Helplessness & horror
Clinical features
• Dissociative symptoms
Natural Man made
Numbness
Disorientation
Impaired cognition
• Autonomic arousal
• Purposeless over activity or stupor
• Begins immediately & lasts up to 3 days
• Occurs in 25% of those exposed
Bereavement War
Treatment: Psychotherapy
Earthquakes Rape
Acute stress reaction
Floods Planedis
Post traumatic stress crash
Adjustment dis
 Adjustment disorders
Emotional or behavioural symptoms occurring within 1-3 moths of stressor

Depressed mood, anxiety, worry,

irritability
Adjustment disorders
Significant social, academic,
occupational functioning
Bereavement Work change
Treated with psychotherapy

•Problem solving approach

Relationship Physical illness • Break defences (anger & guilt)
• Recognise displacement of anger

Symptomatic treatment to lower

Role change Retirement anxiety
 Post traumatic stress disorder
Stress exceptionally threatening
Latency period lasting weeks to months
Epidemiology Clinical features
• 5-10% general population; twice in females Hyperarousal, hypervigilance, insomnia
• 30% trauma victims; up to 300,000 US troops Repeated reliving the trauma
fighting in Iraq & Afghanistan  Flashbacks
Predisposing factors  Vivid nightmares
• Childhood trauma Avoidance & Dissociative symptoms
• Lower social class • Emotional numbness (blunting)
• Young & elderly • Depersonalisation
• Personality disorders • Avoidance of reminders
• History of psychiatric disorder Maladaptive coping
Biological changes  Persistent anger
• Structural damage to amygdale & hippocampus  Drug abuse
• HPA dysfunction, 5 HT, and opioid system  Suicidal attempts
Anxiety & depression
Treatment
Cognitive behaviour therapy
SSRI’s
 Gulf war syndrome
• Quarter (175,000) of US Symptoms
& 6000 of British troops
(55,000) • ↓ Memory & con

• Two chemicals • Persistent headaches

implicated • Fatigue

• Widespread pain
• Pyridostigmine: protect
against nerve gas • Chronic digestive & respiratory
• Pesticides: used to protect symptoms
against sand flies
• Skin rashes