Neurotic disorders

1. Neurotic disorders

2. Psychosis vs. Neurosis

3. Neurosis are classified under F4 in ICD 10 • F40-F49- Neurotic, stress related and somatoform disorders • F40 – phobic anxiety disorders • F 41 – other anxiety disorders • F 42 – Obsessive compulsive disorder • F 43 – Reaction to severe stress and adjustment disorders • F 44 – Dissociative (conversion) disorder • F 45 – Somatoform disorders • F 48 – other neurotic disorders

4. Psychopathology • Disturbances in serotonin, norepinephrine and gamma aminobutyric acid (GABA) appear to be most significant. • Serotonin is thought to be decreased and norepinephrne is thought to be increased in anxiety disorders. • GABA is decreased in anxiety disorders , allowingfor increased cellular excitability.

5. Etiological factors • Psychoanalytic theories • Freud proposed that anxiety is a signal to the ego to take defensive action against the “pressure” from within. If repression is unsuccessful as a defense, other defense mechanisms may result in symptom formation

6. Generalized Anxiety Disorders (GAD) • It is an anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry • It is a common chronic disorder characterized by long lasting anxiety that is not focused on any one subject or situation.

7. Biological theories • 1. Autonomic nervous system • James Lange theory states that subjective anxiety is a response to peripheral phenomena. Stimulation of autonomic nervous system causes cardio vascular, respiratory and GI symptoms

8. 2. Norepinephrine (NE) • Studies have found that, in patients with panic disorder, - adrenergic agonists (isoproterenol) and - adrenergic antagonists (yohimbine) can produce frequent and severe panic attacks, conversely clonodine, an adrenergic agonist, reduces anxiety symptoms in some experimental and therapeutic situations

9. Environmental factors • Trauma, stressful events, changing jobs or schools • GAD s worse during the period of stress • Use and withdrawal from addictive substances, alcohol, caffeine, nicotine etc can worsen anxiety

10. Epidemiology • Onset is usually from childhood to late adulthood • Onset is approximately 31 • More in women • Common in elderly population also

11. symptoms • Cardiovascular • Tachycardia • Chest pain • Palpitations • Flushing • fainting

12. Respiratory • Sighing • Choking • Yawning • Dyspnoea

13. Alimentary symptoms • Dry mouth • Dysphagia • Dyspepsia • Butterflies in stomach • Nausea • Abdominal pain • diarrhea

14. Genito urinary symptoms • Frequency • Hesitation • Sexual dysfunctions • Nerveous symptoms • Tension headache • Blurring of vision • Tinnitus • Tremor • Dilated pupils

15. Musculo skeletal symptoms • Aches and pains • Teeth clenching • Chronic jerks

16. Physiological symptoms • Anxious mood • Worry or fear • Irritability • Inability to relax • Feeling of being unable to cope • Feeling restless • Depersonalization • Initial insomnia • Nightmare

17. Treatment • Medication • Benzodiazepines (valium, librium) • Anti depressants (paxil, prozac, zoloft) • TCA, SSRI • Psychotherapy • CBT • Biofeedback • Relaxation therapy • Supportive therapy

18. Prevention • Stop consuming products contain caffeine • Do not take OTC medicines • Exercise daily and eat healthy diet • Seek counseling help after traumatic experience • Practice stress management techniques

19. Panic disorder • A sudden overwhelming feeling of terror or impending doom. This severe form of emotional anxiety is usually accompanied by behavioral, cognitive and physiological signs and symptoms considered to be outside the expected range of normalcy

20. Classification • F41.0 – panic disorder • F41.1 – Generalized Anxiety Disorder • F 41.2 – Mixed anxiety and depressive disorder • F41.9 – other specified anxiety disorders

21. Epidemiology • Lifetime prevalence estimates range from 1.5 – 5% for panic disorder and 3- 5.6% for panic attacks • Women are more likely to be affected than men by a 2-3 fold factor • Highest incidence is in late adolescence and second peak in mid 30s.

22. Causes • Genetic factors (the concordance rate in monozygotic twins of patients with panic disorder is 80%) • Biochemical factors (reduction in GABA activity in brain) • Malfunctioning of brain structure such as amyldala and hormonal/ adrenaline glands. • Co morbid condition with heridity disorders , such as bipolar disorder and genetic predisposition to alcoholism

23. Medical conditions like hypoglycemia, hyperthyroidism, mitral valve prolapse, labirinthitis and pheochromocytoma can aggravate panic disorder • Stressful life events, life transitions and environment play a role in the onset of panic disorder.

24. psychopathology • Serotonergic model suggests an exaggerated or inefficient post synaptic receptor response to synaptic serotonin • Catecholamine model postulates increased sensitivity to or improper processing of adrenergic CNS discharge, with potential hypersensitivity of presynaptic alpha-2 receptors

25. Lactate model focuses on symptom production by postulated aberrant metabolic activity induced by lactate. • GABA model postulates decreased inhibitory receptor sensitivity, with a resultant excitatory effect • Neuroanatomic model suggests panic attacks are mediated by a fear network in the brain that involves amygdala, hypothalamus and brainstem centers.

26. Clinical features • Shortness of breath and smothering sensations • Pounding and rapid heart beat • Palpitations • Chocking, chest discomfort and pain • Sweating, dizziness, unsteady feelings or fainting • Nausea or abdominal discomfort

27. Depersonalization or derealization • Numbness or tingling sensations • Flushes or chills • Trembling or shaking • Fear of dying or having heart attack • Fear of being out of control, agoraphobia, depression

28. Diagnostic criteria • Recurrent unexpected panic attacks • At least one of the attacks has been followed by 1 month with the following • Persistent concern about having additional attacks • Worry about implications of the attack or its consequences • Significant change in behavior related to the attacks • Presence or absence of agarophobia

29. Treatment • Pharmacotherapy • SSRI • Benzodiazepines • Sedating antidepressants (TCA) • Lorazapam (Avitan) 0.5 -1 mg IV/ IM 1-2mg PO bid/tid • Clonazepam (Klonopin) 0.5-2mg PO bid/tid

30. Psychotherapy • CBT • Psychodynamic psychotherapy • Relaxation techniques • Respiratory techniques • Interoceptive training

31. Nursing management • Panic anxiety • Stay with client and offer reassurance • Maintain a calm, non threatening, matter of fact approach • Use simple words and brief massages.

32. Keep immediate surroundings low in stimuli • Administer tranquilizing medication as ordered by physician • When level of anxiety has been reduced, explore possible reasons for re occurrence • Teach symptoms of escalating anxiety and ways to interrupt its progression

33. powerlessness • Allow client to take as much responsibility as possible for self care practices • Provide client with privacy as needed • Provide positive feedback on decisions made • Assist client to set realistic goals • Help identify areas of life situation that client can control • Encourage verbalization of feelings related to inability

34. Phobia • A phobia is defined as an irrational fear that produces a conscious avoidance of the feared subject, activity or situation. The affected person usually recognizes that the reaction is excessive

35. Classification • Agoraphobia • Social phobia • Specific phobia • Other phobic anxiety disorders • Phobic anxiety disorder, unspecified