Neurotic and stress

related disorders
 Introduction

The term “anxiety neurosis” was first used

by FREUD IN 1895.
It is an unpleasurable emotional state
associated with psychophysiological
changes in response to an intrapsychic
conflict, in contrast to fear, the danger or
threat in anxiety is unreal.
 Epidemiology

• About 2 to 4 % in normal population

• This constituted about 25-30% of psychiatric
consultation in general practice and about 8-10 % of
psychiatric out patients.
• More common in women than men by at least 2:1
• Prevalence rate is 1.5-5% for panic disorders
• 2-3% in OCD
• 8% for PTSD
• 0.6-6 % for agoraphobia
 HOW MUCH IS TOO MUCH

• Anxiety is usually considered as normal reaction to

a realistic danger or threat to biological integrity.
Normal anxiety dissipates, when danger /threat is no
longer present. It is difficult to draw a precise line
between normal and abnormal anxiety:
1. It is out of proportion to the situation that is creating
it. example: Mrs. X witnessed a serious automobile
accident 4 weeks ago, When she was out driving her
car and since that time refuses to drive even to the
grocery store a few miles from her house. when her
husband is available, he must take her whenever she
needs to go.
 HOW MUCH IS TOO MUCH
cont’d…
2. Anxiety interfears with sound,
occupation, and other important areas of
functioning. example: because of
anxiety associated with during her car,
Mrs. X has been forced to quit her job in
a downtown bank for lack of support.
 CLASSIFICATION
F40-F49: Neurotic, stress related and somatization
disorders
F40- phobic anxiety disorder
F41-other anxiety disorders
F42-OCD
F43-Reaction to severe stress, and adjustment disorder
F44- Conversion (Dissociative disorder
F45-Somatoform disorder
F48-other neurotic disorder
 ANXIETY DISORDERS
As Anxiety disorders, as the term suggests, has an
unrealistic, irrational fear or anxiety of disabling
intensity
AGORAPHOBIA: Anxiety about being in places or
situations from which escape might be difficult or in
which help may not be available
PANIC ATTACKS: A discrete period of intense fear or
discomfort which developed abruptly and reached
a peak within 10 minutes.
PANIC ATTACKS
SYMPTOMS
 Anxiety Disorder are classified as
following:-
 Phobic Anxiety Disorder
 Panic Anxiety Disorder
 Generalized Anxiety
Disorder
 TYPES of Neurotic DISORDER
• Panic disorder
Panic disorder with agoraphobia or without agoraphobia

• Phobic disorder
Specific Phobias Social Phobias
• Generalized Anxiety Disorder (GAD)
• Obsessive Compulsive Disorder (OCD)
• Post-traumatic Stress Disorder (PTSD)
• Acute Stress Disorder (ASD)
PANIC
DISORDERS
 PANIC ANXIETY DISORDER
A sudden overwhelming feeling of
terror. This most severe form of
anxiety is accompanied by
behavioral. Cognitive, physiological
signs and symptoms.

Panic attacks occurs suddenly, build

to peak intensity within 10-15 min
and rarely last longer than 30 min.
however repeated attacks may
occurs
.
 PANIC ANXIETY DISORDER
It is characterized by recurrent
anxietyn(panic) attacks that occur at
times unpredictable through certain
situations. Eg. Driving a car.
.
 Thirty minutes for terror
Panic attacks occurs
suddenly, build to peak
intensity within 10-15
minutes and rarely last longer
than 30 minutes. However,
repeated attacks may
continue to recur for hours.
• EPIDEMIOLOGY
• Age at onset for panic disorder varies
but
lay between late adolescence and mid-
30s.
• 2-4% of general population
• Female to male ration is 2:1
• Rarely begins after 50 years
Sign /symptoms
• Palpitations
• Rapid heart rate
• Trembling/shaking
• Shortness of breathg
• Shallow breathing
• Feeling of chocking
• Chest pain
• Abdominal distress
• Feeling of unreality
• Fear of loosing control
• Chills/hot flashes
• Fear of dying
treatment
• Patient teaching
• Cognitive therapy
• Behavioral therapy
• Relaxation technique
• Pharmacological
therapy( antidepressants)
PHOBIC
DISORDER
 PHOBIC DISORDER
 DEFINITION: A persistent fear of some
specific object or often leading to persistent
avoidance of the feared object and situation
or activity.

 CHARACTERRSTICS:
 Presence of fear of an object
 Fear os out of proportion to the danger
perceived
 The patient recognizes the fear as irrational
(Presence of insight)
 Patient is unable to avoid persistent object or
situation
 Course and Prevalence
• Age onset for specific phobia lay between childhood
to mid-20s.
• In community samples current prevalence rate
ranges from 4% to 8.8% and lifetime prevalence
rates ranges from 7.2% to 11.3%.
• Duration: at least 6 months.
• Differential Diagnosis:
 Social phobia.
 Post-traumatic stress disorder
 Obsessive Compulsive disorder
 Hypochondrias
 Anorexia Nervosa and Bulimia Nervosa
 Type of phobia

1)Simple phobia
2)Social phobia
3)Agoraphobia
 SIMPLE PHOBIA

DEFINITION:
irrational fear of specific object or situation.
EPIDEMIOLOGY:
Common in childhood. By early teenage, most of these
fears are lost, but few persist ill later part of life
 SOCIAL PHOBIA
 Is characterized by clinically significant
anxiety provoking by exposure to certain
types of social or performance
situation, which people exposed to
unfamiliar people or to scrutiny by others.
The individual fears that he or she will act
in a way that will be humiliating or
embarrassing.
Duration: at least 6 months.
 Course and Prevalence:
It has an onset in the mid-teens.
Studies have reported a lifetime prevalence
of social phobia ranging from 3% to 13%.
DIFFERENTIAL DIAGNOSIS
 Separation Anxiety disorder
 Generalized Anxiety disorder
 Schizoid Personality disorder
 performance anxiety, stage fright and shyness
 3. agoraphobia:
irrational fear of being in places away from the fzmiliar
setting of home, in crowds or in situations that patients
cannot leave easily
s/s:
Fear of being alone
Fear of leaving home
Fear of being away from home
Fear of using public transport
Fear of theatres
Other symptoms: panic attacks
Multiple phobias
Chronic anxiety
Depersonalization
Somatic deprerssion
OBSESSIVE
COMPULSIVE
DISORDER
 OBSESSIVE COMPULSIVE DISORDER
Obsessive Compulsive Disorder characterized by
obsessions(which cause marked anxiety) and by
compulsions( which serve to neutralize anxiety)
Obsession: are persistent thoughts, ideas, impulses, or
iŵages that seeŵ to iŶvade a persoŶ’s coŶsciousŶess.
Compulsions: are repetitive and rigid behavior or mental
act that a person feels compelled to perform to reduce
distress or anxiety. :
Types
 Verbal compulsion: compel them to repeat expressions, phrases.
 Touching rituals: must touch or avoid touching certain items
 Counting compulsion: driven to count the things they see around them.
 Course and Prevalence
Community studies have estimated a lifetime prevalence
of 2.5% and 1 year prevalence of 0.5%-2.1% in adults.
OCD prevalence is similar in many different cultures.
Age onset is earlier in males than females: between age
6 and 15 for males and between age 20 and 29 years for
females.
Differential diagnosis:
• OCD is not diagnosed if the content of thoughts or activities related to another mental
disorder like Body Dysmorphic disorder or Specific phobia.
• Major depressive disorder.
• Generalized Anxiety disorder.
• Hypochondrias.
• Additional diagnosis of delusional disorder or psychotic disorder not otherwise
GENERALIZED ANXIETY
DISORDER
 GENERALIZED ANXIETY
DISORDER
Chronic, unrealistic & excessive anxiety
and worry existed for 6 months or longer
and can not be attributed to specific factors.
Epidemiology:
• Affects 3% of general population

• More common in women than men.

• Age of onset is early 20’s. but all ager

group including children and elderly
are affected.
 ETIOLOGY

1)GENETIC FACTORS: 15-25% of the

relatives of patient with anxiety
2)Biochemical factors: imbalance in serotonin,
GABA
3)Psychosocial factors: death of loved ones, job
loss or divorce can inc stress and may trigger
anxiety attacks.
4)Medical conditions: caffeine intoxication,
mitral valve prolapsed, seizures etc.
 Sign and symptoms
1) Excessive physiological arousal:
• Shortnes of breath
• Tachycardia
• Dry mouth sweating
• fatigue
• restlesness
2. Distoirted cognitive process:
• Poor concentration
• Unrealistic assessment of problems
• Excessive anxiety and worry over minor matters
3. Poor coping:
• Avoidance
• Procrastination
• Poor problem solving skills
 Differential Diagnosis
 GAD should be made only when the focus
of the anxiety and worry is unrelated to
other disorder like
• Panic disorder
• Obsessive Compulsive disorder
• Hypochondrias
• Separation Anxiety disorder
• Post-traumatic Stress disorder.
 Posttraumatic Stress Disorder
 PTSD may occur after someone has experienced a
serious traumatic event such as a natural disaster,
war, rape, murder or torture.
 Characterized by recurrent, persistent flashbacks,
reliving the event or nightmare of the events along
with avoidance of reminder of it.
Causes:
• Military combat/war
• Kidnapping
• Robber
• Abuse: physical/ sexual
 CAUSES OF PTSD CONT’D…

• Terrorist attack
• Natural/ man made disaster
• Severe automobile accident
• Seeing a dead body or part
• Death of close one
• Diagnosis of a life threatening diseases
 SIGN/SYMPTOMS
 Falshbacks
 Detachment from other people
 Anhedonia
 Aggresion
 Depersonalization
 Chronic anxiety or tension
 Dec. self esteem
 hopelessness
 Poor impulse control
 Hyperarousal
 Course and Prevalence
 PTSD can occur at any age, including childhood.
 Community based studies reveal a lifetime prevalence
for PTSD approximately 8% of adult population in
United States.
 Differential Diagnosis
Acute Stress disorder
Adjustment disorder
Flash backs in PTSD should also be
distinguished from hallucinations,
illusions and other perceptual
disturbances.
 ACUTE STRESS DISORDER
 Acute Stress Disorder (ASD) is
characterized by symptoms similar to
those PSTD that occur immediately in the
aftermath of an extremely traumatic
event.
 Symptoms:
• Depersonalization.
• Dissociative amnesia (inability to recall traumatic events).
• Subjective sense of numbing, detachment or emotional
responsiveness.
• De realization.
 Traumatic event is persistently re-experienced
• Thoughts.
• Recurrent images.
• Flashback episode.
• Sense of reliving the experience.
 Marked symptoms of anxiety or increased
arousal
• difficulty in sleeping.
• irritability
• poor concentration
• hyper vigilance
• motor restlessness
• exaggerated startle response
Course and Prevalence
• Symptoms experienced during or immediately
after the trauma, last for at least 2 days, and
maximum 4 weeks and occur within 4 weeks of
the traumatic event.
• ASD in few available studies, rates ranging from
14% to 33% have been reported in individuals
 Differential Diagnosis

Distinguish from mental disorder due to general

medical condition( e.g. head injury) and from
Substance Induced disorder (e.g. related alcohol
intoxication.
 Major depressive disorder in diagnosed in addition
to the diagnosis of Acute stress disorder.
 PTSD
 Adjustment Disorder
 THEORIES ON
ANXIETY
DISORDER
 The Psychodynamic Theory
 The Humanistic- Existential
Theory
 The Behavioral Theory
 The Neuroscience Theory
 The Cognitive Theory
 The Socio-cultural Theory
 THE PSYCHODYNAMIC THEORY
The fundamental concept is that anxiety is at the
root of neurosis.
 Anxiety stemmed in the form of unacceptable ID
impulses attempting to break through into
consciousness and behavior.
In all neurosis the relief of anxiety is sought through
various defense mechanism.
 For example, in panic attack, the cause that is id impulse moves
closer to the boundaries of conscious mind, resulting in rapid building up
of anxiety. The ego responds with desperate effort to repression, once
the ego regain upper hand the impulse once again safely repressed.
 THE HUMANISTIC-EXISTENTIAL
THEORY
 Humanistic- existential theorists describe anxiety as
the outcome of the conflict between the individual
and society.
 According to humanists the source of neurosis is the
discrepancy between the self concept and the ideal
self.
 If the way we perceive ourselves is very different
from the way we would like to be, we feel incapable
of ŵeetiŶg life’s challeŶges, aŶd aŶdžietLJ results.
THE BEHAVIORAL THEORY
According to behaviorists avoidance is a
response learned to relieve anxiety.
 For example, Agoraphobia is a strategy to
avoid panic attacks in public.
Avoidance learning is a major source of
anxiety and is two-stage process:
• Through respondent conditioning, a neutral
stimulus becomes anxiety arousing.
• The avoidance response relieves anxiety through
negative reinforcement and becomes habitual.
 Another way of acquiring fear reactions is
through modeling.
THE NEUROSCIENCE THEORY
 Anxiety disorders appear to have genetic
basis.
In Norwegian study, the concordance
rate for panic disorder in MZ twins was
31 percent, as opposed to 0 percent for
D twins (Torgersen, 1983).
 Abnormalities in the neurotransmitters
gamma-amino butyric acid (GABA) and
serotonin may have a particular role in
susceptibility to generalized anxiety
disorder.
Serotonin is a major player in OCD and
social phobia.
 THE COGNITIVE THEORY
 According to the cognitive theory, people with
anxiety disorders misperceive or misinterpret
internal and external stimuli.
 Events that are not really threatening, and anxiety
results.
In the case of panic disorder, if a person upon
experiencing unusual bodily sensations
catastrophically, as a signal that he or she is about
to pass out or have a heart attack, then panic could
result.
 THE SOCIO-CULTURAL THEORY
According to socio-cultural theorists, phobic and
GAD are more likely to develop in people who are
confronted with societal pressure.
Stressful changes have occurred in the society
have
also increased the prevalence of anxiety disorders.
TREATMENT OF
ANXIETY
DISORDER
 PSYCHOLOGICAL
TREATMENT
• Systematic Desensitization
FOR ANXIETY DISORDER
• Flooding and Implosive
Therapy
• Modeling
• Exposure Treatment
• Group Therapy
• Rational-emotive behavior
therapy
• Self-instruction training
• Relaxation training
• Biofeedback training
• Do you become anxious when you face anything that
reminds you of that traumatic event?
• Are you afraid that you will be in a situation where you will
not be able to escape?
• Do you feel that you worry excessively about many things?

• What is the differential diagnosis of panic disorder with

agoraphobia with specific phobias?
• How can anxiety disorder can be treated through systematic
desensitization?
• What is psychodynamic view regarding anxiety disorders?
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Carson. R.C., Butcher J. N & Mineka. S., (2001). Abnormal Psychology and Modern Life. ( 11 th Ed). Published by Pearson

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Comer. R. J., (1995). Abnormal Psychology. (2 nd Ed). Published by W. H. Freeman and Company, USA.

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM–IV). Washington,

DC: APA.