Neurosis

Mental Health Center

The First Affiliated Hospital of
Chongqing Medical University

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 Neurosis
Prevalence : 5%(worldwide)
2.1%(China)

Age: begin in the 16-35 age.

 Common Features
1) Onset of neuroses often associated with psychological
and social factors.

2) There are certain quality and personality basis before

the disease appearing.

3) Main symptoms include brain disorders,emotional

symptoms,obsessive-compulsive symptoms,
hypochondriac symptoms,a variety of physical discomfort
and so on.
 Common Features
4) Patients without psychotic symptoms,the disease pain is
obvious,patients have a sense of disease and desire to
seek treatment.

5) Patients social function is relatively complete and their

behavior is usually maintained within the scope of social
norms.

6) The course is more persistent.

1.Mental stress factors:

2.Personality factors:

3.Biological factors:
1.Brain disorders symptoms:

2.Emotional symptoms:

3.Obsession and compulsion:

4. Hypochondriac symptoms

5.Physical symptoms

6.Somnipathy:
Anxiety disorders
Description

Anxiety is characterized by heightened

arousal (physical symptoms such as tension.
tachycardia, tachypnea, tremor) accompanied
by apprehension, fear, obsessions, or the lick.

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Anxiety：It is a normal emotional response
that occurs in many scene in normal people.

Anxiety disorder：When there is no external

stress, the patient has obvious anxiety, or the
power of patient's anxiety significantly exceeds the
stress-induced response power, and makes the
patient feel pain and damage the social function.
The diagnosis of anxiety disorder should be considered:
an extreme or inappropriate fear or worry
coupled with some degree of life impairment.

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 Anxiety and Fear
Anxiety：a negative mood state characterized
by physiological symptoms (bodily
tension) and apprehension about the
future.

Fear：immediate alarm reaction to danger,

involves fight or flight response,
sympathetic nervous system reactions.
Ø Phobia Dsorder(PD)
Ø Generalized Anxiety Disorder(GAD)
Ø Panic Disorder(PD)
Ø Obsessive-Compulsive Disorder(OCD)
 Distribution of anxiety disorders (12-month prevalence)
by age and gender

*Without PTSD.

Baldwin DS, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders:
recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology
19(6) (2005) 567–596 14
 *Without PTSD
Baldwin DS, et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders:
recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology
19(6) (2005) 567–596 15
Comorbidity of Neuroses and Depression

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Rubinchik et al. Prim Care Companion J Clin Psychiatry 2005;7:100–105
1.The prevalence rate in females is
significantly higher than that in males.
2.The overall prevalence of anxiety disorder is
very high, nearly one in five people have
suffered from anxiety disorder in their life.
3.Anxiety disorders are highly comorbidity
with each other and are common with
depression.
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l A 33-year-old woman was out shopping one
day when she suddenly became very faint
and lightheaded. She noticed her heart was
beating fast and she could not get her breath.
She felt she was suffocating and felt to the
ground. She thought she was going to die.
Passers-by came to her aid and an
ambulance was called. She was taken to
hospital. Her symptoms subsided and
medical examination was normal.
 Typical case

l Over the next few weeks, she developed

further similar attack. She began to worry
that something was wrong with her heart
and visited her doctor several times. She
began to be afraid to go out in case she had
another attack. When she was out, she
could not stop checking her pulse in case
she had another attack. Her anxiety in
relation to going out got worse and worse.
Definition:
Panic disorder is characterized by recurring,
spontaneous, unexpected anxiety attacks with
rapid onset and short duration.

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Panic attacks involve severe anxiety
symptoms of rapid onset. These symptoms
climb to maximum severity within 10 minutes
but can peak within a few seconds.

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Typical symptoms:shortness of breath,
tachypnea, tachycardia, tremor, dizziness, hot
or cold sensations, chest discomfort, and
feelings of crazy or out of control.
A minimum of four symptoms is required to meet
the diagnosis of panic attack. The symptoms
usually last for less than 1 hour and most
commonly diminish within 30 minutes.

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Diagnostic basis:the attack has at least 3 times in
1 months and every time no more than 2 h.

Intermittent period: not have obvious other

symptoms
Characteristics
(1)There is no real danger in the episode of attacks.
(2)The attacks is not limited to known or predictable
circumstances.
(3)There are almost no anxiety symptoms in the
intermittent period of
panic attacks.
(4)The attacks is not the result of physical fatigue
physical disease(such as
hyperthyroidism)or substance abuse.
l A 33-year-old woman was out shopping one day
when she suddenly became very faint and
lightheaded. She noticed her heart was beating
fast and she could not get her breath. She felt
she was suffocating and felt to the ground. She
thought she was going to die. Passers-by came
to her aid and an ambulance was called. She
was taken to hospital. Her symptoms subsided
and medical examination was normal.
 Typical case

l Over the next few weeks, she developed further

similar attack. She began to worry that
something was wrong with her heart and visited
her doctor several times. She began to be afraid
to go out in case she had another attack. When
she was out, she could not stop checking her
pulse in case she had another attack. Her anxiety
in relation to going out got worse and worse.
28
A. Pharmacologic Treatment:
Panic in many relatively mildly ill
patients requires no medication and can
be managed with psychotherapy alone.

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Medication should be considered if the panic
disorder impairs functioning
(1) if agoraphobia is present or developing.
(2) if major depression (currently or by history)
or a personality disorder is present.
(3) if the patient reports significant suicidal
ideation.
(4) if the patient voices a strong prefer ace for
medication management.

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Tricyclic antidepressants(TCA), especially
imipramine, have the best-established research
record.

Amitriptyline and clomipramine also have

reasonable empirical support for their
effectiveness.

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The monoamine oxidase inhibitors(MAOIS),
especially phenelzine, have relatively strong
empirical support. Like imipramine, phenelzine
reduces the frequency and intensity of panic
attacks. It also appears to have a substantial anti --
anxiety and antiphonic effect.

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Research data support the effectiveness
of SSRI antidepressants. Including
paroxetine,fluoxetine. and sertraline, in
the treatment of panic disorder.

These drugs have become more popular in

recent years and have supplanted other
antidepressants and benzodiazepines in
the treatment of panic disorder.

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As mentioned earlier, low-dose
benzodiazepine management can be used
on an as-needed basis to reduce
anticipatory anxiety and facilitate
exposure activities.

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B. Psychotherapy:
Only traditional behavioral treatments and
cognitive-behavioral psychotherapy have
significant empirical evidence to support their
effectiveness. Considerable evidence supports
the effeciveness of cognitive-behavioral therapy
for treatment of panic disorder. This approach
helps patients to recognize the relationships
between specific thoughts (cognitions) and the
anxiety that they experience.

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These thoughts represent
misinterpretations of external, or more
commonly internal, cues as being
threatening.

Successful treatment would help the patient

to discover the true relationship between
specific internal or external cues and
their anxiety, and to correctly interpret
the cues as benign.

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1.Agoraphobia

2.Social phobia

3.Specific phobia
l Phobias are irrational fears involving avoidance
of objects or situations that are extremely
unlikely to cause harm and that most people
approach without discomfort.

l Avoidance is common.

l Exposure therapy and anxiolytics or

antidepressants are useful.
l The NIMH-ECA study reported a 6-month prevalence of
agoraphobia of 3.8% for women and 1.8% for men.

l Some of the higher prevalence rates in females may be

culturally determined.

l The age at onset peaks in the early 20s, and onset after age
40 is uncommon.
l The essential feature of agoraphobia is a fear or
anxiety about being in places or situations from
which a graceful and speeding escape may be
difficult or embarrassing if the patient felt
discomfort.

l Typical fears include being outside the safety of

the home, traveling on public transport, begin in
crowded places, or having to queue. Situations
likely to induce fear and avoidance.

l often become discouraged, depressed.

l A 23-year-old woman who had experienced panic while
driving on an expressway on three separate occasions
became worried about driving on the expressway again;
worrying about it brought on another panic attack. She
stopped driving on the expressway but still experienced
extreme anxiety in other situations in which means of express
were not readily available, such as standing in a supermarket
checkout line, sitting in church, or sitting under a hair dryer
at the beauty parlor. She became increasingly worried about
panic attacks and avoided more and more settings in which
they might occur, resulting in a feeling of helplessness. She
was able to continue working only because a trusted friend
conveyed her to and from work.
l Estimates of the lifetime prevalence of social phobia
ranges from 3 to 13%.

l Social phobia is more common in women than men(the

National Comorbidity Survey study 12-month prevalence
is 6.6% for males and 9.1% for females), but more males
than females are seen for treatment.

l At any one time, approximately 2% of the general

population may suffer from the disorder.

l Age at onset is usually around puberty, with peak

presentation for treatment in the 20s and few new cases
emerging after age 30.
l Social phobia (also called social anxiety disorder) is
characterized by a marked and persistent fear of social
situations in with embarrassment may occur.

l Individuals may worry that others will judge them to

be foolish or stupid.

l Public speaking may be a particular problem.

A medical student ranking in the top 10% of his class sought
treatment before making a decision to drop out of medical
school during the first clinical rotation in his third year. He
had always experienced extreme anxiety whenever called on
to speak in class and had successfully avoided such
presentations through high school, college, and the first 2
years of medical school. He had taken pains to select a
medical school in which he thought formal oral presentations
were not required. At the beginning of his junior year, he was
informed that he would have to make a “medical advances”
presentation 4 months later. Although he quickly developed
the topic and was confident of his material, he felt that he
could not face the ordeal of making the presentation.
Anticipatory anxiety had already begun to mount to a level
that interfered with his sleep and performance on the wards.
l Specific phobias are extremely common, and approximately
8% of the normal population have a diagnosable disorder.

l In many cases, however, the degree of impairment is

insufficient to warrant treatment, and only 1% of the
general population seek treatment.

l Specific phobias are twice as common in women than in

men.

l Peak onset is in childhood.

l The essential feature of specific phobia is marked or
persistent fear of specific, circumscribed objects or situations.

l Exposure to the feared object results in immediate anxiety or

a frank panic attack.

l There is usually marked avoidance.

l

l The fear is considered to be excessive or unreasonable.

 fainting
·animal type: this usually begins in childhood and common feared objects
are snakes, spiders, dogs, birds, various insects, mice and cats

·natural environment type: the fear is precipitated by aspects of the

natural environment, e.g. storms, heights or water

·blood-injection-injury: the fear is cued by seeing blood or undergoing a

medical procedure (e.g. receiving an injection or dental examination)

·situational type: the fear is cued by specific forms of transportation

including flying, crossing bridges, elevators and other small closed spaces, etc
l A 32-year-old man presented for treatment
because he had fainted every time he had had
blood drawn since age 12. This experience led to
fearful avoidance of doctors and venipuncture in
this otherwise healthy and physically fit
individual. He sought treatment because he
avoided routine health monitoring and might find
it difficult to seek care for acute medical problems.
He also reported embarrassment about his
inability to have blood drawn without fainting
unless recumbent.
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A.Pharmacologic Treatment:
some drug treatments have been used.
Benzodiazepines are commonly used to reduce the
anxiety associated with specific and social phobias.
β- Blockers such as propranolol have been used with
success to reduce the autonomic hyper arousal and
tremor associated with performance situations.
Controlled clinical trials have shown antidepressants,
such as migraine, to be beneficial in treating social
phobia, especially the generalized type of social
phobia.
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B. Psychotherapy:
Behavioral therapy and CBT are common options
for the treatment of phobia. A typical treatment
involves relaxation training, usually coupled with
visualization of the phobic stimulus, followed by
progressive desensitization through repeated
controlled exposure to the phobic status. This
method is generally followed by extinction of the
anxiety response. Cognitive-behavioral therapy adds
the dimension of managing the catastrophic
thoughts associated with exposure to the situation.

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GAD typically begins in early adult life, is
seen slightly more commonly in women,
and is usually chronic.
Although this disorder is fairly common,
it is seen more frequently in general
medical practice than in psychiatry
practice .

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Patients with GAD typically experience persistent
worry of variable severity across time that often
leads them to their primary care clinician for help.
Continuous care and attention is critical to the
recognition and treatment of this disorder.
Further, patients with GAD have a high rate of
comorbidity with major depression; GAD comes
closest to the classic concept of the anxiety
neurosis.

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GAD is a syndrome of persistent worry coupled
with symptoms of hyper arousal. Most patients
with GAD do not recognize themselves as having
a psychiatric disorder, even though the symptoms
can be quite disabling. These patients are much
more likely to present in a general medical setting
than in a psychiatrist’s office, For this reason,
primary care clinicians must be particularly
sensitive to patients’ emotional needs.

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For as long as he could remember, a 53-year-old man
had “worried” about things that never came to pass;
their possible occurrence had little foundation in
reality, and if they did occur, they were unlikely to be
of serious consequence. He described himself as
always feeling tense and restless, sometimes trembling
or being on edge, and feeling irritable and easily
fatigued. He had trouble falling and staying asleep
because of “worries”. At times of peak worry, he
described symptoms of autonomic distress, including
dry mouth, sweating, tachycardia, urinary frequency,
and diarrhea. These symptoms were present most days
to a greater or lesser degree and never worsened
suddenly (milder than that in panic disorder).
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A. Pharmacologic Treatment:
Patients with GAD are likely to receive
benzodiazepines. Even though
psychotherapies and other medications
are clearly beneficial. Most clinicians
worry about the potential for
benzodiazepine abuse. Epidemiologic
studies, however, demonstrate that
legitimate clinical use far outweighs any
abuse .

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Buspirone, a serotonin 1A receptor partial agonist,
is an alternative to benzodiazepine.
The tricyclic antidepressant and SSRI /SNRI
antidepressant have demonstrated significant
benefit in the treatment of GAD. The therapeutic
effect is delayed, but severely anxious patients
appear to improve.

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B. Psychotherapy: Two psychotherapeutic
approaches are helpful in treating GAD.
Behavioral therapy can teach patients
progressive deep muscle relaxation while
they imagine anxiety-inducing stimuli, If
the patient avoids situations that generate
significant anxiety, progressive
desensitization can be helpful. An
alternative is cognitive-behavioral
therapy.

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The clinical feature of obsessions are
aversive experiences of dread and
uncertainty, or the disturbing sense that
something is not right or is incomplete.
Obsessive thoughts are the particular
ideas associated with obsessive
experiences. They are often bizarre or
inadequate as explanations for these
experiences.

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Compulsions take the form of willed
responses directed at reducing the
aversive circumstances associated with
the obsessive thoughts. They are
generally carried out in concordance with
the ideation surrounding the obsessions.
They can take the form of overt
behaviors or silent mental acts such as
checking, praying, counting, or some
other mental ritual.

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Most adults with OCD recognize that their fears
and behaviors are unrealistic or excessive.
But the patient was in great pain because he
couldn't get rid of it.
Attempt to escape and depressive reaction may be
a prominent secondary symptom in OCD.

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71
A. Behavioral Therapy:
Behavioral therapy for OCD involves
exposure and response prevention.
According to learning theorists, patients
with OCD have learned an inappropriate
active avoidance response to anxiety
associated with circumstances that
trigger their OCD symptom.

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 The clinician must encourage the
patient to experience the aversive
condition (exposure) without performing
the compulsion (response prevention).

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B. Pharmacologic Treatment:
1. Anti-depressant
2. Anti-anxiety
3. Anti-psychotic

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C. Neurosurgery: Neurosurgery is the
treatment of last resort. Neurosurgical
procedures include limbic leucotomy,
anterior capsulotomy, and subcaudate
tractotomy, Estimates of clinically
significant improvement are 25-90%,
although controlled studies have not been
undertaken.

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Patients who somatize psychosocial
distress commonly present in medical
clinical settings, Approximately 25% of
patients in primary care demonstrate
some degree of somatization, and at least
10% of a disease process.

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Somatizers rarely seek help from
psychiatrists at their own initialtive, and
they may resent any implication that
their physical distress is related to
psychological problems.

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l 1. What is the pathological anxiety?
l 2. What is the definition of panic disorder/ a
panic attack?
l 3. What is the symptoms of a panic attack?
l 4. What are the features of generalized
anxiety disorder?
l 5. What are the features of Agoraphobia, Social
phobia or Specific phobia separately?
l 6. How do we treat the anxiety disorders?
l 7.
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