‫بسم الله الرحمن الرحيم‬

Neurotic,
stress-related and somatoform
disorders

:PRESENTED BY
D. FATIMA SALAH
PSYCHIATRY TRAINEE
 Overview of anxiety
disorders:
 Generalized anxiety disorder .
 Phobic anxiety disorders .
 Panic disorder .
 Post-traumatic stress disorder .
 Obsessive–compulsive disorder .
 Medically unexplained symptoms
 Definition
 Neurosis:
is a collective term for psychiatric disorders
characterized by distress, that are non-organic, have a
discrete onset and where delusions and hallucinations
are absent.
 Anxiety:

is an unpleasant emotional state involving

subjective fear and somatic symptoms.
 Every human experiences anxiety, but if these
anxieties become excessive or inappropriate they are
described as an illness.
:Clinical features of neuroses
 Associated cognitions include worries or fears that are
inappropriate or excessive.
 Associated behaviors include avoidance or escape
from the situation that causes anxiety.
 Depressive symptoms are very common in patients
with neuroses.
 In history taking the interviewer should ask about rate
of onset, duration and severity of the anxiety, whether
the anxiety arises spontaneously or in response to a
specific situation, and whether there are any
psychiatric or medical conditions which may
predispose to anxiety.
:Symptoms of neurosis
:Classification of neuroses
 Neuroses can be categorized based on the nature of the
anxiety and the circumstances in which the anxiety
occurs.
 Anxiety disorders can be divided into two main
categories:
Conditions associated with
anxiety
:Definition
 Generalized anxiety disorder (GAD):
is a syndrome of ongoing, uncontrollable,
widespread worry about many events or thoughts
that the patient recognizes as excessive and
inappropriate.
 Symptoms must be present on most days for at
least 6 months duration.
:Pathophysiology/Aetiology
:Clinical features

Common features of presentation specific to GAD are
listed below (‘WATCHERS’):
1. Worry (excessive, uncontrollable).
2. Autonomic hyperactivity (sweating, ↑ pupil size, ↑ HR).
3. Tension in muscles/Tremor.
4. Concentration difficulty/Chronic aches.
5. Headache/Hyperventilation.
6. Energy loss .
7. Restlessness .
8. Startled easily/Sleep disturbance (difficulty getting to
sleep then intermittent awakening and nightmares).
:ICD-10 Criteria for GAD

A. A period of at least 6 months with

prominent tension, worry and feelings of
apprehension about everyday events and
problems.
B. At least four of the following
symptoms with at least one symptom of
autonomic arousal:
• Symptoms of autonomic arousal:
palpitations, sweating, shaking/tremor, dry
mouth.
:Treatment
 Biological:
I. The first-line drug treatment of choice is an SSRI
(sertraline is recommended) which has anxiolytic
effects.
II. If this does not help an SNRI (e.g. venlafaxine or
duloxetine) can be offered.
III. If both of these are ineffective or not tolerated,
pregabalin may be used.
IV. Medication should be continued for at least a year.
V. Benzodiazepines should not be offered except as
short-term measures during crises as they can cause
dependence.
:Definition
 Phobia:
is an intense, irrational fear of an object, situation, place
or person that is recognized as excessive (out of proportion to
the threat) or unreasonable.
 Agoraphobia:
Agoraphobia literally means a ‘fear of the marketplace’.
It is a fear of public spaces or fear of entering a public space from
which immediate escape would be difficult in the event of a panic
attack.
 Social phobia (social anxiety disorder):
A fear of social situations which may lead to humiliation,
criticism or embarrassment.
 Specific (isolated) phobia:
A fear restricted to a specific object or situation (excluding
Specific phobia:
 Phobia from animals, environmental, blood (or injection or
injury), situational or others
:Clinical features
 Biological:
Tachycardia is the usual autonomic response, however in
phobias of blood, injection and injury, a vasovagal response
(bradycardia) is produced, commonly leading to fainting (syncope).
 Psychological:
Include unpleasant anticipatory anxiety, inability to
relax, urge to avoid the feared situation and, at extremes, a fear of
dying.
 Agoraphobia is strongly linked to panic disorder.
 Indeed the ICD-10 divides agoraphobia into: agoraphobia with
panic disorder and agoraphobia without panic disorder.
Management:
 Try to establish a good rapport with the patient.
 Remember, particularly with social phobia, it may have been very
challenging for the patient to attend the appointment.
 Advise avoidance of anxiety-inducing substances, e.g. caffeine
 Screen for significant co-morbidities such as substance misuse
and personality disorders.
 Refer to a specialist if there is a risk of self-harm, suicide, self-
neglect or significant co-morbidity.
:Definition
 Panic disorder is characterized by recurrent, episodic, severe
panic attacks, which are unpredictable and not restricted to
any particular situation or circumstance.
:Pathophysiology/Aetiology
:Epidemiology and risk factors
 Panic disorder has a prevalence of 1% in the general population.
 It is three times more common in ♀.
 The usual age of onset is late adolescence.
Clinical features:
 Panic symptoms usually peak within 10 minutes and rarely persist
beyond an hour.
 ICD-10 Criteria for the diagnosis of panic disorder:
A. Recurrent panic attacks that are not consistently associated
with a specific situation or object, and often occur spontaneously.
The panic attacks are not associated with marked exertion or
with exposure to dangerous or life-threatening situations.
B. Characterized by ALL of the following:
(1) Discrete episode of intense fear or discomfort.
(2) Starts abruptly.
(3) Reaches a crescendo within a few minutes and
lasts at least some minutes.
(4) At least one symptom of autonomic arousal:
palpitations, sweating, shaking/ tremor, dry mouth.
:Management
 SSRIs are first-line but if they are not suitable, or there is no
improvement after 12 weeks, then a TCA, e.g. imipramine or
clomipramine may be considered.
 Benzodiazepines should not be prescribed.
 CBT is the psychological intervention of choice, focusing on
recognition of panic triggers.
 Self-help methods include support groups and encouraging
exercise to promote good health.
 NICE offers a stepped care approach
Post traumatic stress
:disorder
 PTSD is a response to a catastrophic life
experience in which the patient re-experiences the
trauma, avoids reminders of the event, and
experiences emotional numbing or hyper-arousal
 Symptoms arise less than 6 months after the
event and must last for at least one month


 Criteria:
1. Traumatic exposure: Having experienced or witnessed a
traumatic event (e.g., war, rape, or a natural disaster). The event was
potentially harmful or fatal, and the initial reaction was intense fear or
horror
2. Persistent re-experiencing of the event (e.g. in dreams,
flashbacks, or recurrent recollections)
3. Avoidance of stimuli associated with the trauma (numbing):
places, thoughts, blocking memory, detachment, restricted range of affect
or sense of foreshortened future
4. Persistent symptoms of increased arousal (e.g. difficulty
sleeping, out-bursts of anger, exaggerated startle response or difficulty
concentrating)
  Treatment:
o Psychotherapy: CBT, eye movement desensitization or
hypnotherapy
o pharmacotherapy: SSRIs, hypnotic for sleep
disturbances (e.g. zopiclone), anxiolytics, mood stabilizer for intrusive
Obsessive–compulsive
disorder
Definition:
 Obsessive–compulsive disorder (OCD) :
is characterized by recurrent obsessional
thoughts or compulsive acts, or commonly both.
 Obsessions:

Unwanted intrusive thoughts, images or urges

that repeatedly enter the individual’s mind. They are
distressing for the individual who attempts to resist them
and recognizes them.
 Compulsions:

Repetitive, stereotyped behaviors or mental

acts that a person feels driven into performing. They
are overt (observable by others) or covert (mental
Pathophysiology/Aetiology:
 There are a number of theories for the aetiology of
OCD:
 Biological:
o Related to ↓ serotonin and abnormalities of the frontal
cortex and basal ganglia.
o Twin and family studies suggest a genetic
contribution to OCD particularly with pediatric
onset.
o Childhood group A beta-haemolytic streptococcal
infection may have a role in causing OCD symptoms
by setting up an autoimmune reaction which
damages the basal ganglia (this is called PANDAS:
 Psychoanalytic:
Filling the mind with obsessional thoughts in
order to prevent undesirable ideas from entering
consciousness.
 Behavioral:

Compulsive behavior is learned and maintained

by operant conditioning.
The anxiety created by the obsession is
reduced by performing the compulsion, and
subsequently the need to perform the compulsion is
increased.
: Clinical features
 Common compulsions include:
checking (70%), hand washing (50%),
dealing with contamination (45%), doubting (35%),
counting (35%) & over concern with symmetry (30%)
 CT and MRI findings include bilateral reduction in
caudate size
 The difference between OCD & Schizophrenic delusions
is that people with Schizophrenic delusions don’t try to
stop their thoughts.
 Also Schizophrenic delusions are not as intrusive as in
OCD
 Obsessions or compulsions must share ALL of the following
features (FORD Car):
1. Failure to resist: At least one obsession or
compulsion is present which is unsuccessfully resisted.
2. Originate from patient’s mind: Acknowledged
that the obsessions or compulsions originate from their own
mind, and are not imposed by outside persons or influences.
3. Repetitive and Distressing: At least one
obsession or compulsion must be present which is
acknowledged by the patient as excessive or unreasonable.
4. Carrying out the obsessive thought (or
compulsive act) is not in itself pleasurable, but reduces
anxiety levels.
DD:
Management:
1.CBT (including ERP – exposure and response
prevention):
ERP is a technique in which patients are
repeatedly exposed to the situation which causes them
anxiety (e.g. exposure to dirt) and are prevented from
performing the repetitive actions which lessen that
anxiety (e.g. washing their hands).
After initial anxiety on exposure, the levels of
anxiety gradually decrease.
2. Pharmacological therapy:
SSRIs are the drug of choice in OCD.
NICE recommends fluoxetine, fluvoxamine,
paroxetine, sertraline or citalopram.
Clomipramine is an alternative drug
therapy.
This can be combined with citalopram in
more severe cases.
Alternatively, an antipsychotic can be added
in with an SSRI or clomipramine.
thanks