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Neurotic Disorders [Compatibility Mode] Neurotic Disorders Department of Psychiatry 11stst Faculty of Medicine Charles University, Prague Head: Prof. MUDr. Jiří Raboch, DrSc. Neurotic Disorders Neurotic, stressstress--related,related, and somatoform disorders have common historical origin with the concept of neurosis and association of a substantial proportion of these disorders with psychological causation. Mixtures of symptoms, especially anxiety and depressive ones are common in these disorders About one fourth of the population in developed countries will suffer from neurotic disorders during its lifetime course. With the exception of social phobia their frequency is higher in women than in men. Neurotic, Stress--RelatedRelated and Somatoform Disorders (F40--F48)F48) F40 Phobic anxiety disorders F41 Other anxiety disorders F42 Obsessive--compulsivecompulsive disorder F43 Reaction to severe stress, and adjustment disorders F44 Dissociative [conversion] disorders F45 Somatoform disorders F48 Other neurotic disorders F40 Phobic anxiety disorders F40 Phobic anxiety disorders F40.0 Agoraphobia F40.1 Social phobias F40.2 Specific (isolated) phobias F40.8 Other phobic anxiety disorders F40.9 Phobic anxiety disorder, unspecified Phobic Anxiety Disorders In agoraphobia, social and specific phobias, anxiety is evoked predominantly by certain wellwell--defineddefined situations or objects, which are external to the individual and are not currently dangerous. As a result, these situations or objects are characteristically avoided or endured with dread. Phobic anxiety fluctuates from mild uneasy to terror. The individual’s concern may focus on individual symptoms such as palpitations or feeling faint and is often associated with secondary fears of dying, losing control, or going mad. The anxiety is not relieved by the knowledge that other people do not regard the situation in question as dangerous or threatening. Agoraphobia „Agoraphobia“ --thethe fear from marketplace. Agoraphobia includes various phobias embracing fears of leaving home: fears of entering shops, crowds, and public places, or of traveling alone in trains, buses, underground or planes. The lack of an immediately available exit is one of the key features of many agoraphobic situations. The avoidance behaviour causes sometimes that the sufferer becomes completely housebound. Most sufferers are women. Onset --earlyearly adult life. The lifetime prevalence --betweenbetween 5—5 —7%.7%. High coco--morbiditymorbidity with panic disorder; depressive and obsessional symptoms and social phobias may be also present. Agoraphobia Anticipative Fobic Anxiety Anxiety Specific Situation Social Phobias Clinical picture --fearfear of scrutiny by other people in comparatively small groups leading to avoidance of social situations The fears may be ••discretediscrete --restrictedrestricted to eating in public, to be introducedintroduced to other people, to public speaking, or to encounters with the opposite sex ••diffusediffuse --socialsocial situations outside the family circle.circle. Direct eyeeye--toto--eyeeye confrontation may be stressful.stressful. Low selfself--esteemesteem and fear of criticism. Symptoms may progress to panic attacks. Avoidance --almostalmost complete social isolation. Usually start in childhood or adolescence. Estimation of lifetime prevalence --betweenbetween 10--1310 13 %. It is equally common in both sexes. Secondary alcoholism.. Social Phobias Anticipative Fobic Anxiety Anxiety Social Stress Specific (Isolated) Phobias 1.1. Fears of proximity to particular animals •• spiders ((arachnophobiaarachnophobia)) •• insects ((entomophobiaentomophobia)) •• snakes ((ophidiophobia)ophidiophobia) 2.2. Fears of specific situations such as •• heights (acrophobia) •• thunder (keraunophobia) •• darkness (nyctophobia) •• closed spaces (claustrophobia) 3.3. Fears of diseases, injuries or medical examinations •• visiting a dentist •• the sight of blood (hemophobia) or injury (pain — odynophobia) •• the fear of exposure to venereal diseases (syphil(syphilididophobia)ophobia) or AIDSAIDS--phobia.phobia. Usually arise in childhood or early adult life and can persist for decades if they remain untreated. Lifetime prevalence -- between 1010--20%.20%. F41 Other Anxiety Disorders F41 Other anxiety disorders F41.0 Panic disorder ((episodicepisodic paroxysmal anxiety)) F41.1 Generalized anxiety disorder F41.2 Mixed anxiety and depressive disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified Other Anxiety Disorders Manifestations of anxiety are also the major symptoms of these disorders, however, it is not restricted to any particular environmental situation. Panic Disorder The essential features are recurrent attacks of severe anxiety (panic attacks) which are not restricted to any particular situation or set of circumstances. Typical symptoms are palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalisation or derealization). Individual attacks usually last for minutes only. The frequency of attacks varies substantially. Frequent and predictable panic attacks produce fear of being alone or going into public places. The afflicted persons used to think that they got a serious somatic disease. The course of panic disorder is longlong--lastinglasting and isis complicated with various comorbidities, in half of the cases with agoraphobia. The estimation of lifetime prevalence moves between 11--3%.3%. Panic Disorder Panic Anticipative Attac Anxiety General Anxiety Disorder The essential feature is anxiety lasting more than 6 months, which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances. Symptoms: continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort .. Fears that the patient or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings. The estimation of lifetime prevalence moves between 44--66 %. This disorder is more common in women, and often related to chronic environmental stress. Its course uses to be fluctuating and chronic connected with symptoms of frustration, sadness and complicated with abuse of alcohol and other illicit drugs. Mixed Anxiety and Depressive Disorder Symptoms of both anxiety and depression are present, but neither of symptoms, considered separately, is sufficiently severe to justify a diagnosis of depressive episode or specific anxiety disorder. Some autonomic symptoms, such as tremor, palpitations, dry mouth, stomach churning, must be present. Individuals with this mixture of comparatively mild symptoms are frequently seen in primary care. Etiology of Anxiety Disorders The etiology of anxiety disorders is not exactly known. Genetic factors were found to play a role. Nongenetic factors, such as various stressful life events during early or later stages of ontogenesis were thought to be even more important. Several different neurotransmitter systems have been implicated in these disorders, including the noradrenergic, GABA, and serotoninergic systems in some parts of the brain. The role of CO22 in the etiology of panic disorder is seriously discussed. Clinical Management of Anxiety Disorders Treatment of anxiety disorders: ••variousvarious psychotherapeutic techniques cognitivecognitive--behaviouralbehavioural therapy (CBT) psychodynamic approaches ••psychopharmacotherapypsychopharmacotherapy benzodiazepines (alprazolam, clonazepam) -- for several weeks (potential for abuse, development of tolerance and addiction) Buspirone -- little abusive potential; especially GAD, not effective in panic disorder; longer use is necessary betabeta--blockingblocking drugs --forfor the short treatment of performance anxiety, especially somatic symptoms like tremor antihistaminics various types of antidepressants --SRIsSRIs (clomipramine, citalopram, fluoxetine, fluvoxamine, paroxetitle, sertraline), MOAIs (tranylcypromifle), RIMA (moclobemide) and SNRI (venlafaxine); well tolerated, no abuse potential Recommendation : to start the treatment with a brief course of benzodiazepines as well as with antidepressants for a longer period and to combine the drug treatment with various types of psychotherapy. Commonly Used Anxiolytics Drug Commonly used Elimination halftime dosage (mg) (hours) Alprazolam 0,5-6 12-15 Bromazepam 3-15 12 Diazepam 5-30 24-72 Chfordiazepoxied 10-50 24-100 Clobazam 20 -30 20 Clonazepam 1-8 34 Clorazepate 15-60 60 Lorazepam 1-4 11-13 Medazepam 10-30 29 Oxazepam 30-90 4-20 Tofizopam 50-300 6 Buspirone 20-30 2-11 Hydroxyzine 300-400 12-20 F42 Obsessive--CompulsiveCompulsive Disorder (OCD) F42 Obsessive--compulsivecompulsive disorder F42.0 Predominantly obsessional thoughts or ruminations F42.1 Predominantly compulsive acts ((obsessional rituals)) F42.2 Mixed obsessional thoughts and acts F42.8 Other obsessive--compulsivecompulsive disorders F42.9 Obsessive--compulsivecompulsive disorder, unspecified Obsessive--Compulsive Disorder (OCD) Obsessional thought are ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form. They are recognized as the individual’s own thoughts, even though they are involuntary and often repugnant. Common obsessions include fears of contamination, of harming other persons or sinning against God. Compulsions are repetitive, purposeful,
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