F40-F48 NEUROTIC, STRESS-RELATED

AND SOMATOFORM DISORDERS

 F40 Phobic anxiety disorders

Neurotic, stress-
stress-related and
 F41 Other anxiety disorders
somatoform disorders in ICD 10
 F42 Obsessive-compulsive
Obsessive compulsive disorder
 F43 Reaction to severe stress, and
adjustment disorder
Prof. Elmars Rancans
Department of psychiatry and narcology, RSU  F44 Dissociative [conversion] disorder
 F45 Somatoform disorders

E.Rancans, RSU

Anxiety: Introduction

Super Ego  Anxiety warns of an external or internal threat

 It prompts the person to take the necessary steps
to p
prevent the threat or to lessen its
consequences
Ego
 It mobilises us in the periods of stress
 In excessive dosages it causes maladaptation of
the body
ID
E.Rancans, RSU E.Rancans, RSU

Acute reaction to stress Grief as a process

The grief process is the inner turmoil that follows
bereavement and the subsequent adaptation by an
Event
individual to the new situation.

 The grief process consists of:

 yearning and searching - the urge to recover the
Neglecting l
loss predominates
d i t and d searching
hi ttakes
k place,
l
Bargaining  disorganisation and despair – the loss is accepted and
attempts to recover the loss are stopped,
Feelings of guilt  reorganisation of behaviour.
Anger Mobilisation
• Bowlby's original classification consisted of the latter three
Identification and phases listed above (yearning and searching;
acceptance disorganisation and despair; reorganisation of behaviour).

Suicide
Bowlby (1985); Rees (1997)
E.Rancans, RSU E.Rancans, RSU

1
 Differential diagnosis of grief F40-F48 NEUROTIC, STRESS-RELATED
reactions AND SOMATOFORM DISORDERS
 A normal grief reaction persists for 2-6 months  F40 Phobic anxiety disorders
and improves steadily without specific
treatment.  F41 Other anxiety disorders
 F42 Obsessive-compulsive
Obsessive compulsive disorder
 However, if a person in a prolonged (atypical)
grief reaction has the signs and symptoms of  F43 Reaction to severe stress, and
major depression, this should be treated.
adjustment disorder
 F44 Dissociative [conversion] disorder
 F45 Somatoform disorders
Clayton (1982); Zisook (1994)

E.Rancans, RSU E.Rancans, RSU

One-year prevalences of Anxiety

One- Panic Attack
Disorders:: USA vs. Europe
Disorders Diagnostic Criteria
One-year prevalence % A discrete period of intense fear or discomfort which
develop abruptly and reach a peak within 10 minutes:
0 5 10 15 20
Palpitations, Chest pain
Generalised 3.1 pounding heart
Anxiety Disorder 1 Nausea
NCS-R, 2005 Sweating
6.8 ESEMeD,, 2004
Social Phobia Chills or
12
1.2
Trembling or hot
2.7 shaking flushes
Panic Disorder
0.8 Numbness or
8.7 Dry mouth tingling
Specific Phobia sensations
3.5
Shortness of Feeling dizzy,
Any Anxiety 18.1 breath
Disorder 6.4 lightheaded
Feeling of
Kessler RC, et al. Arch Gen Psychiatry. 2005;62: 617-627
choking Loosing control,
The ESEMeD/MHEDEA 2000 Investigators. Acta Psychiatrica going crazy
E.Rancans, RSU
Scandinavica 2004: 109 (Suppl. 420): 28-37 E.Rancans, RSU

Panic Disorder Diagnostic Criteria Agoraphobia

Key features of panic disorder with or without
Diagnostic Criteria
agoraphobia
 Recurrent and unexpected panic attacks
and
 At least 1 of the attacks has been followed by 1 month
of 1 of the following:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its
consequences (eg, losing control, having a heart attack, going
crazy)
(c) a significant change in behavior related to the attacks
 Anxiety about being in places or situations
 From which escape might be difficult (or embarrassing) or
 In which help may not be available in the event of having a
panic attack or panic-like symptoms, for example
• Being
g outside the home alone
• Being in a crowd or standing in a line
• Being on a bridge
• Traveling in a bus, train, or automobile
 The situations are avoided (eg, travel is restricted) or
else are endured with marked distress or with anxiety
about having a panic attack or panic-like symptoms, or
require the presence of a companion

E.Rancans, RSU 2000.

DSM-IV-TR E.Rancans, RSU 2000.
DSM-IV-TR

2
 The Clinical picture of Social Anxiety Common Somatic Complaints in
Disorder SAD
 Fear or avoidance of social situations Stuttering Blushing

 The individual fears that he or she will act in a way

(or show anxiety symptoms) that will be humiliating
or embarrassing.g Palpitations Sweating
 Situations avoided or endured with anxiety or
distress
 Recognized as excessive or unreasonable Trembling
“Butterflies”
 Very distressing or disabling and shaking

DSM-IV-TR.
E.Rancans, RSU Washington, DC: American Psychiatric Association; 2000. Beidel DC.
E.Rancans, RSUJ Clin Psychiatry. 1998;59(suppl 17):27-31.

Social Anxiety Disorder

Screen for SAD in Patients with:
 Median age of onset: 13 years old
 Onset after the age of 25 is rare
 Depression
 Chronic, unremitting, lifelong disorder
 Alcohol or substance abuse
 2 subtypes
bt off SAD
SAD:  History of anxiety since childhood
 Generalized: impairment in 4+ social situations; familial  Somatic complaints
 Specific (limited, performance): 1 to 2 specific social situations;  Tremor
probably nonfamilial
 Sweating
 Significant academic and social functioning impairment  Blushing
 >50% unable to complete high school  Body dysmorphic disorder

Judd LL.RSU
E.Rancans, J Clin Psychiatry. 1994;55(suppl):5-9. E.Rancans, RSU

The Clinical picture of GAD Frequent Somatic Complaints of GAD

Muscle tension,
 A syndrome of excessive anxiety, worries and Trembling, aching, soreness
feelings of apprehension about everyday events and pounding hart
problems Dry mouth
 Minimum duration of 6 months Feeling dizzy
Difficulty in
 Associated symptoms
breathing
 Psychic: restlessness, irritability, difficulty concentrating, Cold, clammy
tension, being easily fatigued hands Sweating
 Broad range of somatic anxiety symptoms
Urinary
Nausea or frequency
diarrhea

Adopted from ICD-10 (1994) and DSM-IV (2000)

E.Rancans, RSU DSM-IV-TR.
E.Rancans, RSU Washington, DC: American Psychiatric Association; 2000.

3
 Obsessive-Compulsive Disorder
Obsessive- Disorder::
The Clinical picture of GAD (cont.)
Epidemiology and Course
 Many with GAD report anxiety all their lives, but  Previously thought of as rare - prevalence 0.05%1
clinically significant GAD usually starts after age
 Lifetime prevalence is estimated to be 2.5% in recent
20
studies2,3
 Approximately twice as prevalent in women  Men and women are affected in equal numbers
 Chronic course with fluctuating symptoms, often  Onset is generally in adolescence or early adulthood
exacerbated by stress
 84% of OCD sufferers have a chronic, waxing and
 Significant distress or impairment waning course4

Wittchen HU et al. Arch Gen Psychiatry 1994 1Rudin (1953); 2Robins et al (1984); 3Weissman et al (1994);
Adopted from ICD-10 (1996) and DSM-IV (2000) 4Rasmussen & Tsuang (1986); DSM-IV-TR™ 2000;
E.Rancans, RSU E.Rancans, RSU

Obsessive--compulsive disorder
Obsessive Dimensional clusters of OCD

Obsessions and/or Compulsions  Contamination obsessions and cleaning

compulsions

 Repetitive and unpleasant  Counting, arranging, ordering, symmetry

 Recognized origination in own mind obsessions
b i andd compulsions
l i
 Attempted (unsuccessful) resistance
 Harm, sexual and religious obsessions and
 Significant distress/impaired functioning
related compulsions

 Hoarding and collecting obsessions and

OCD compulsions
E.Rancans, RSU E.Rancans, RSU Leckman et al (1998)

PTSD – Certain Traumatic

Epidemiology of PTSD
Events
In a study,
Increase Risk
 The lifetime incidence of Select traumatic events and the estimated risk for developing PTSD*
15
experiencing a traumatic event
severe enough to cause PTSD is 70
Lifetime prevalence %

10.4 more than 50%* 60

53.8%
10
49.0%
 Approximately
pp y 20% of individuals 50
Risk of PTSD (%)

exposed to a traumatic event will go 40

5 on to develop PTSD 30
31.9%

5 23.7%

 PTSD is the 5th most prevalent 20 16.8%

15.4% 14.3%
10.4%
major psychiatric illness* 10
7.3%
3.8%

0 0
 Twice as common among females
Female Male Held Rape Severe Other Serious Shooting Sudden Child’s Witnessing Natural
captive/ beating sexual accident or unexpected life- killing/ disaster
tortured/ assault or injury stabbing death of a threatening serious
kidnapped close friend illness injury
or relative
*Based on results from the Detroit Area Survey of Trauma, which was a telephone survey conducted among a
*From Part 2 of the NCS. A total of 5877 respondents participated in the survey, which was
representative sample of 2181 individuals aged 18 to 45 years in the Detroit area in 1996.
conducted among individuals aged 15 to 54 years, from September 1990 to February 1992.
E.Rancans,
Kessler RSU
1995, 1999; Breslau 1991; Resnick 1993. E.Rancans, RSU 1998.
Breslau

4
 Core Features of PTSD PTSD Diagnostic Criteria
 The person has been exposed to a traumatic event:
 The person experienced, witnessed, or was confronted with
event(s) involving actual or threatened death or serious
 Intrusive symptoms injury, or a threat to the physical integrity of self or others
 The person’s response involved intense fear, helplessness,
 Avoidance behavior or horror
Trauma  Numbing
 The traumatic event is persistently reexperienced:
 Recurrent, intrusive distressing memories and dreams
 Hyperarousal  Flashbacks episodes
 Intense psychological distress when exposed to reminiscent
symptoms cues

E.Rancans, RSU E.Rancans, RSU DSM-IV-TR 2000.

PTSD Diagnostic Criteria (cont’d) PTSD Diagnostic Criteria (cont’d)

 Persistent avoidance of stimuli associated with the
traumatic event and numbing of general
responsiveness:  Persistent symptoms of hyperarousal not present
before the traumatic event (as manifested by 2 or
 Avoiding thoughts, feelings, or conversations connected to more of the following):
the event
 Difficulty falling or staying asleep
 Avoiding activities, places, or people connected to the event
 Irritability or outbursts of anger
 Amnesia about certain important aspects of the event
 Problems concentrating
 Decreased interest in once-enjoyed activities
 Hypervigilance
 Feeling detached from others
 Emotional numbing/restricted range of affect  Exaggerated startle response
 A sense of foreshortened future

DSM-IV-TR 2000. DSM-IV-TR 2000.

E.Rancans, RSU E.Rancans, RSU

PTSD Clinical Course PTSD

 PTSD symptoms usually present within the first 3 Somatic Presentation
months following the traumatic event:
 Acute: Duration of symptoms is less than 3 months
Patients with PTSD often present with somatic
symptoms such as:
 Chronic: Duration of symptoms is 3 months or more  Gastrointestinal symptoms
 Delayed onset: symptom onset may be delayed for months or  Cardiovascular symptoms
years after the traumatic event
 Neurological symptoms
 Symptoms of PTSD may persist for months or years  Musculoskeletal symptoms
following the traumatic event  Headaches
 The National Comorbidity Survey found that 40% of patients  Low back pain
with PTSD continued to experience symptoms for 10 years  Respiratory symptoms
 Approximately 50% of all cases of PTSD are chronic

E.Rancans, RSU DSM-IV-TR™ 2000; Kessler 1995. E.Rancans, RSU McFarlane 1994; Irwin 1996; Shalev 1990.
.

5
F44 Dissociative [conversion] disorder
 Dissociative amnesia - the predominant
disturbance is one or more episodes of inability to
recall important personal information, usually of a
traumatic or stressful nature, that is too extensive
to be explained by ordinary forgetfulness.
 Dissociative fugue - the predominant disturbance
is sudden, unexpected travel away from home or
one's customary place of work, with inability to
recall one's past.
 Dissociative Identity Disorder - the presence of
two or more distinct identities or personality
states (each with its own relatively enduring
pattern of perceiving, relating to, and thinking
about the environment and self).
E.Rancans, RSU
Somatization disorder
 A history of at least 2 years' complaints of multiple and
variable physical symptoms that cannot be explained by
any detectable physical disorders.
 Preoccupation with the symptoms causes persistent
distress and leads the patient to seek repeated (three or
more) consultations or sets of investigations with either
primary care or specialist doctors.
 There is persistent refusal to accept medical
reassurance that there is no adequate physical cause for
the physical symptoms.
E.Rancans, RSU
Somatization disorder
Genitourinary symptoms
(9) dysuria or complaints of frequency of micturition;
(10) unpleasant sensations in or around the genitals;
(11) complaints of unusual or copious vaginal discharge;
 Skin and pain symptoms
(12) blotchiness or discoloration of the skin;
(13) pain in the limbs, extremities, or joints;
(14) unpleasant numbness or tingling sensations.
E.Rancans, RSU
F 45 Somatoform Disorders
 Somatization disorder
 Hypochondriacal disorder
 Somatoform autonomic dysfunction
y
 Persistent somatoform pain disorder
E.Rancans, RSU
Somatization disorder
There must be a total of six or more symptoms from the
following list, with symptoms occurring in at least two
separate groups:
 Gastrointestinal symptoms
(1) abdominal pain;
(2) nausea;
(3) feeling bloated or full of gas;
(4) bad taste in mouth, or excessively coated tongue;
(5) complaints of vomiting or regurgitation of food;
(6) complaints of frequent and loose bowel motions or discharge of
fluids from anus;
 Cardiovascular symptoms
(7) breathlessness without exertion;
(8) chest pains;
E.Rancans, RSU
Hypochondriacal disorder
 Either of the following must be present:
(1) a persistent belief, of at least 5 months' duration, of the presence
of a maximum of two serious physical diseases (of which at least
one must be specifically named by the patient);
(2) a persistent preoccupation with a presumed deformity or
disfigurement (body dysmorphic disorder).
 Preoccupation with the belief and the symptoms causes
persistent distress or interference with personal functioning
in daily living and leads the patient to seek medical
treatment or investigations (or equivalent help from local
healers).
 There is persistent refusal to accept medical reassurance
that there is no physical cause for the symptoms or
physical abnormality. (Short-term acceptance of such
reassurance, i.e., for a few weeks during or immediately
after investigations, does not exclude this diagnosis.)
E.Rancans, RSU