Neurotic Disorders for Psychiatric trainees.

1. Neurotic Disorders for Psychiatric trainees. Dr Keith Gilhooly ST5 Psychiatrist

2. General points. • 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.

3. Licences.( Arbitary). • 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

4. Psychodynamic understanding of anxiety disorders. • Focus on; 1.Intrapsychic conflicts. 2.Unconcious fantasies. 3. Defense mechanisms 4. Compromise function of symptoms.

5. 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)

6. 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.

7. 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.

8. Phobias- theories • 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”

9. Phobias. Theories. • 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.

10. Phobias F 40ICD 10 Diagnostic Common factors and differences • 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.

11. Subsection B (12 symptoms) • 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.

12. 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.

13. 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.

14. Agorophobia F40.0 • With above criteria(SectionA) specificfear or avoidance must be of at least 2 of the following. • Crowds • public spaces • travelling alone • travel away from home.

15. 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.

16. 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

17. Social Phobias F40.1 • Fear or avoidance specifically of • Focus of attention. • Potentially embarrassing or social situations • May be specific eg eating, vomiting, pub speaking.

18. 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.

19. 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.

20. 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

21. Simple Phobias • 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

22. Treatment.CBT • 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”

23. Treatments CBT • Modelling • Implosion • Flooding no better than graded exposure.

24. Psychodynamic. ??? What conflict symptoms represent. Repressed impulses brought to counciousness. Little Hans (Freud) • Medications-generally not used

25. Some unusual Phobias • Pogonophobia -Beards • Bogyphobia -Bogeyman • Panophobia -Everything • Syngenesophobia -Relatives • ??Hippopotomonstrosesquippedaliophobia. -Long words

26. Phobic Disorders..

27. 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.

28. 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

29. 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)

30. 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.

31. CBT. • Teach about body responses? Thinking errors about dying. • Relaxation techniques • Control hyperventilation

32. Generalised Anxiety Disorder F41.1 • 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.

33. 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%

34. 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.

35. 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

36. 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

37. 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

38. Obsessive Compulsive Disorder • 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

39. OCD • 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

40. 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

41. Psychodynamic Theory • 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.

42. CBT • (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.

43. Thought =Action • Failing to prevent harm= causing harm. • No attenuation of concern by low probability

44. 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

45. Acute Stress Reaction • Occurs following exceptional stress • Lasts hours to days • May involve anger, depression and withdrawal. • Resolves on removing the stressor

46. Post Traumatic Stress Disorder • Affects 1-5% (more subclinical) • Event is perceived as life threatening often with helplessness • Involves- • Reliving the event • Avoiding things associated with the event • Increased arousal eg anxiety • Numbing of response eg anhedonia

47. PTSD • 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.

48. Somatoform Disorders • Characterised by physical symptoms persisting despite negative findings • Somatisation disorder (Briquets syndrome)- multiple, variable sx in different systems for >2 years. Uncommon (0,1-0,2%) with F:M 20:1. • Onset in teens to 20s • High comorbidity

49. Somatoform Disorders • 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.

50. 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