Symptoms Psychosis Neurosis

Hallucinations + -

Delusions + -

Thought disorder + -

Reality testing Impaired Intact

Insight Impaired Retained

 Neurotic, stress-related and
somatoform disorders
Symptom or group of symptoms

Behaviour greatly effected but socially

acceptable

Insight and reality testing retained

Personality not disorganised

 Epidemiology
Prevalence Marriage
 Age group 25-44  Protective factor for males
 Life time 40%
 Mean number 2.1
Childhood behaviour &
 General practice 9%
neurosis
 Mixed anx & dep 80%  No relation with neurosis
Life events risk  Conduct disorder related to
antisocial personality dis
 Vulnerability factors
 Long term difficulties Mortality
 Provoking factor  Higher 1.5 times
Socioeconomic status  Risk of suicide & substance
 Lower social class & educational abuse
status Outcome after one year
 Urban areas  25% improve
 50% variable course
 25% deteriorate
 Generalised anxiety disorder
Disproportional to threat or more prolonged
Clinical features

Psychological Genitourinary
 Worrying thoughts • Frequency of micturition
 Fearful anticipation • Erectile difficulty
Neuromuscular
Tremor
Somatic (3) •
• Aches & pains
Gastrointestinal
• Dry mouth Sleep disturbances
• Difficulty swallowing • Early insomnia
Respiratory • Night terrors
• Hyperventilation Co morbidity (60%)
• Difficulty breathing
• Phobic or depressed
Cardiovascular
• Palpitations • Substance abuse
• Chest oppression
 Panic disorder
Recurrent attacks of severe anxiety not restricted to any situation

Biological basis
• Biochemical: Sodium lactate & carbon
dioxide induce attacks
• First degree relatives X 4 times
• ↑ bf right parahippocampal area
• Neurotransmitter abnormalities: NA,
5HT, GABA
Clinical features
Psychological:
• Overwhelming fear of dying/losing
control/going mad Co morbidity (90%)
Somatic: • Anxiety & depression
• Dyspnoea/chest oppression/dizziness
• Sweating/palpitation/flushing/trembling • Substance abuse
• Nausea/abdominal discomfort Prognosis
• 30% recover
• 50% recurrences, symptoms mild
• 20% chronic
 Agoraphobia
Multiple phobic symptoms with high levels of anxiety

Epidemiology Avoidance
Commonest phobic disorder
75% females • Crowds
Premorbid dependency traits • Public transport
50% have history of panic disorder
• Confinement
Clinical features • Cinemas/theatres
Fear
• Leaving home
Anticipatory anxiety
• Being alone
• Being trapped
Prognosis
Anxious thoughts
(fainting & losing control) • H/O panic disorder better
outcome

• Duration > 6 months

prolonged fluctuating course
 Obsessive compulsive disorder
Recurrent thoughts, impulses, or images despite efforts to exclude them
Prevalence 2%, slightly more common in females
Premorbid personality
OCPD in one third
OCPD leads to depression more often
Thoughts
• Intrude against will
• Recognised as own but senseless
• Are resisted
Content
• Contamination
• Pathological doubt
• Symmetry
• Sexual &Aggressive
Ruminations
• Repetitive inconclusive thoughts
• “Meaning of life”
Images
• Inside head
• Sexual, aggressive nature
Compulsions (Obsessional rituals)
• Checking
• Washing
• Restricted to one place in one third
Anxiety & depression common
Organic basis
• Increased bf orbito frontal cortex
• Small size caudate nucleus
• 5HT receptors supersensitive
Associated with
• Encephalitis lethargica
• Sydenham’s chorea
• Tourette syndrome
• Brain trauma
Secondary to
• Depression 30%
• Anorexia nervosa
• Somatoform disorders
 Anxiety disorders
Differential diagnosis Management
Generalised anxiety disorder Drugs
Physical illnesses Benzodiazepines Alprazolam 0.25mg BD
• Thyrotoxicosis SSRI’s Fluoxetine 20mg/D
• Phaeochromocytoma Tricyclic Antidepressants
• Hypoglycaemia Imipramine 150mg/D
Substance abuse Clomipramine 150mg/D
• Alcohol withdrawal MAOI’s Moclobemide 300mg/D
• Amphetamine & cocaine abuse B-Blockers Propanolol 20mg BD
• Excessive use of caffeine Azapirone Buspirone 5mg TDS
Phobic anxiety
• Ischaemic heart disease Behavior therapy
• Paranoid & psychotic states
• Desensitisation
• Post traumatic stress disorder
• Depression
• Relaxation therapy
• Personality disorders • Exposure & response prevention
(Avoidant, schizoid, & paranoid)
Cognitive psychotherapy
 Somatoform disorders

Physical symptoms Dissociative disorders

(Hysteria) Dissociative amnesia
Sudden onset
Females 10 times more, lower socio •
Circumscribed personal memory loss
educational background •
Dissociative fugue state
Stress related; physical symptom • Wandering in amnesic state
without corresponding pathology • Behaviour purposeful (new identity)
Symptoms: Dissociative stupor
Motionless for hours
• blindness, deafness, tunnel vision •
Muscle tone normal
•
• Aphonia, seizures, paralysis Exclude organicity, alcohol, or substance abuse,
Associated features epilepsy
• Primary & secondary gain
• La belle indifference
• identification

90% recover; 25% develop CNS

disease
 Somatoform disorders
(Types)
Somatisation disorder
• More common in females
• 20% 1st degree relatives; F/H
antisocial personality disorder &
alcoholism
• Multiple physical complaints
Chest/cardiac
Back/joint pains
Menstrual symptoms
• Mood swings/irritability
• Dramatic & inconsistent histories
• Seek immediate relief
• Extensively investigated &
treated
• Runs chronic course
Hypochondriasis
• Equally common both sexes
• No familial aggregation
• Preoccupation with having serious
and progressive disease
• Common regions: head, neck,
abdomen
• May have obsessional & phobic
quality but no resistance or
avoidance
• May be secondary to:
Depression
Anxiety
Psychosis
• Seek reassurance & investigations
 Somatoform disorders
Aetiology
Psychoanalytic theory
• Conflict between threatening ideas
and impulses results in anxiety
which gets converted into
symptoms (primary gain)
• Care & sympathy received
constitutes secondary gain
Sociological theory
• Sick role exempts from social
obligations
• Illness behaviour is determined by
patient’s ethnic, cultural, and
educational background
Treatment
• Do not confront
• Impossible to make distinction
between cons/uncons origin
• Examine and investigate with
minimum fuss
• Reassure
• Minimise secondary gains
• Reward symptom-free periods
• Allow discard symptoms
without losing self-esteem
• Abreaction
 Defence mechanisms
Automatic psychological
measures
Used universally & not limited to
psychiatric disorders
Indicate both health & disease
Repression: Thoughts & feelings
unacceptable to consciousness
are thrust back into unconscious
Denial: Automatic distortion of outer
reality
Projection: Attribute disowned &
ascribed to somebody else
Reaction formation: Developing
opposite to the one being
defended against
Displacement: Transfer of affect,
usually anger or fear, from one
person to another
Rationalisation: Justifying
reasoning after the event
Undoing: Acts carried out to
cancel out the previous act
Regression: Reversal to earlier
modes of functioning
Turning against the self: Deflection
of hostile & disadvantageous
behaviour towards self
Sublimation: Harmful urges given
socially acceptable expression
Compensation: Development of
abilities to conceal defect
Grief reaction
Abnormal grief
• More intense
• Onset delayed
• Lasting > 6 months
Risk factors
Sudden, horror deaths
Ambivalent, dependent relationships
Features
Denial
Pseudo hallucinations & illusions
Anxiety & depressive features
Identification symptoms
Treatment
Address deceased in past tense
Discuss last days before death
Visit grave
Symptomatic treatment for depression
 Stress related disorders
Stress
Acute stress reaction
Stress: Overwhelming threat
Helplessness & horror
Clinical features
• Dissociative symptoms
Natural Man made
Numbness
Disorientation
Impaired cognition
• Autonomic arousal
• Purposeless over activity or stupor
• Begins immediately & lasts up to 3 days
• Occurs in 25% of those exposed
Bereavement War
Treatment: Psychotherapy
Earthquakes Rape
Acute stress reaction
Floods Planedis
Post traumatic stress crash
Adjustment dis
 Adjustment disorders
Emotional or behavioural symptoms occurring within 1-3 moths of stressor

Depressed mood, anxiety, worry,

irritability
Adjustment disorders
Significant social, academic,
occupational functioning
Bereavement Work change
Treated with psychotherapy

•Problem solving approach

Relationship Physical illness • Break defences (anger & guilt)
• Recognise displacement of anger

Symptomatic treatment to lower

Role change Retirement anxiety
 Post traumatic stress disorder
Stress exceptionally threatening
Latency period lasting weeks to months
Epidemiology Clinical features
• 5-10% general population; twice in females Hyperarousal, hypervigilance, insomnia
• 30% trauma victims; up to 300,000 US troops Repeated reliving the trauma
fighting in Iraq & Afghanistan  Flashbacks
Predisposing factors  Vivid nightmares
• Childhood trauma Avoidance & Dissociative symptoms
• Lower social class • Emotional numbness (blunting)
• Young & elderly • Depersonalisation
• Personality disorders • Avoidance of reminders
• History of psychiatric disorder Maladaptive coping
Biological changes  Persistent anger
• Structural damage to amygdale & hippocampus  Drug abuse
• HPA dysfunction, 5 HT, and opioid system  Suicidal attempts
Anxiety & depression
Treatment
Cognitive behaviour therapy
SSRI’s
 Gulf war syndrome
• Quarter (175,000) of US
& 6000 of British troops
(55,000)
• Two chemicals
implicated
• Pyridostigmine: protect
against nerve gas
• Pesticides: used to protect
against sand flies
Symptoms
• ↓ Memory & con
• Persistent headaches
• Fatigue
• Widespread pain
• Chronic digestive & respiratory
symptoms
• Skin rashes