Neurotic, Stress-related and

Somatoform Disorders-2

Dr. Fidia Mumtahan

 Neurotic disorders

1. Anxiety Disorders:
-Generalized Anxiety Disorder (GAD)
- Panic Disorder
-Mixed Anxiety-Depressive Disorder
- Phobic Anxiety Disorders
2. Reaction to severe stress and Adjustment
Disorders
3. Obsessive-Compulsive Disorder (OCD)
4. Dissociative & Conversion Disorders
5. Somatoform Disorders
6. Other Neurotic Disorders
Obsessive-Compulsive
Disorder (OCD)
 Obsessive-compulsive disorder 
• It is a potentially disabling illness that traps people in
endless cycles of repetitive thoughts and behaviors.

• People with OCD are affected by recurring and distressing

thoughts, fears, or images they cannot control.

• The anxiety produced by these thoughts leads to an

urgent need to perform certain rituals or routines
(compulsions).

• The compulsive rituals are performed in an attempt to

prevent the obsessive thoughts or make them go away.
 Obsession
• An idea, impulse or image which intrudes into the
conscious awareness repeatedly.

• It is recognized as one’s own idea, impulse or image but is

recognized as ‘egoalien’ (foreign to one’s personality).

• It is recognized as irrational and absurd (insight is present).

• Patient tries to resist against it but is unable to do.

• Failure to resist, leads to marked distress.

 Typical Obsessions
• Doubts (e.g. Did I turn off the stove? Did I lock the
door? Did I hurt someone?)

• Fears that someone else has been hurt or killed

• Fears that one has done something criminal

• Fears that one may accidentally injure someone

• Worry that one has become dirty or contaminated.

 Compulsions
• Repetitive behaviors (e.g., hand washing, checking)
or mental acts (e.g., praying, counting) that the
person feels driven to perform in response to an
obsession.

• It is aimed at either preventing or neutralizing the

distress or fear arising out of obsession.

• Insight– present so the patient realizes the

irrationality of compulsion.

• The behavior is performed with urge or impulse to

act.
 Typical Compulsions
• Checking again and again

• Cleaning/washing again & again

• Doing things in a certain number of times

• Doing things in a certain order, with symmetry

• Doing and then undoing things as feels not perfect

• Mental acts such as counting.

Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder

 There is significant distress or an impairment

in functioning due to the obsessions or
compulsions.

 Persistent, recurring thought (obsession) that

reflect exaggerated anxiety or fear.
 Although Obsessive-Compulsive Disorder (OCD) and
Obsessive-Compulsive Personality Disorder (OCPD)
share some related features, they are two different
disorders.

 As such, it is possible for a person to have both

disorders.

 The primary distinction between these two disorders

is
 the presence of obsessions and compulsions in OCD
 the absence of obsessions and compulsions in OCPD
 Clinical types of OCD
• Four clinical syndromes have been described,
although admixtures are commoner than pure
syndromes

 Washer

 Checkers

 Pure obsessions

 Primary obsessive slowness

 Washers
 This is the commonest type.

 Here the obsession is of contamination with dirt, germs,

body excretions.

 The compulsion is washing of hands or the whole body

repeatedly many times a day.

 It usually spreads on to washing of clothes, washing of

bathrooms, bedrooms, door knobs and personal articles
gradually.
 Checkers
 In this type the person has multiple doubts, e.g. the door
has not been locked, kitchen gas has been left open,
counting of money was not exact etc.
 The compulsion is checking repeatedly to remove the
doubt.
Pure obsession
 This syndrome is characterized by repetitive intrusive
thoughts, impulses or images which are not associated
with compulsive acts.
 The content is usually sexual or aggressive in nature.
Primary obsessive slowness

 A relatively rare syndrome characterized by

severe obsessive ideas and /or extensive
compulsive rituals, in the relative absence of
manifested anxiety.

 This leads to marked slowness in daily activities.

 Aetiology of OCD
• Psychoanalytical theories: attempt to suppress
instinctual drives – aggressiveness

• Biological theories: Brain injury/trauma/acute

disease and/or neurochemical (less serotonin);
Genetic factors

• Behavioural and Cognitive theories.

 OCD - Management
 Behavior therapy

 Pharmacotherapy
o SSRIs, Clomipramine (TCA)
o Augmentation with Risperidone
o Clonazepam

 Electroconvulsive Therapy

 Outcome 60% respond to SSRIs but relapse is common on

cessation of treatment.
 Predictors of poor outcome are male sex, early onset and
obsessional slowness.
 Dissociative &
Conversion Disorder
Dissociative Disorder
 Dissociation means the separation of
thoughts, feelings, or experiences from the
normal stream of consciousness and memory.

 Dis-association - disconnecting or lowering the

strength of associated connection.
 Dissociative Disorder
 Disruption of-
• Consciousness
• Memory
• Identity
• Perception of the environment.

 Examples of dissociative symptoms include the experience

of detachment or feeling as if one is outside one’s body,
and loss of memory

 Dissociative disorders are frequently associated with

previous experience of trauma.
 Dissociative Disorder

 This group of illness also lacks the evidence of

proximate organic illness or patho-
physiological disturbance

 Often occur with other psychiatric disorders

e.g. Depression, Post–Traumatic Stress
disorder, substance abuse disorder and
personality disorders
 Clinical feature
– Disturbance in the normally integrated functions
of consciousness, identity and/ or memory.

– Onset is usually sudden and the disturbance is

usually temporary. Recovery is often abrupt.

– Usually there is a precipitating stress before the

onset. There is a clear relationship between the
stressor and the onset of the illness.
 Types
 Detailed physical examination and
investigations do not reveal any abnormality

 Common clinical types of dissociative disorder

are-
• Dissociative Amnesia
• Dissociative Fugue
• Dissociative identity disorder
• Other Dissociative disorder
 Dissociative Amnesia
• Commonest clinical type of dissociative disorder.

• Occurring most commonly in adolescent and

young adults.

• Characterized by a sudden inability to recall

important personal information, particularly
concerning stressful or traumatic life events.
 Dissociative Amnesia
• The amnesia can not be explained by everyday
forgetfulness and there is no evidence of an underlying
medical illness.

• It follows a traumatic or stressful life situation.

• During the amnestic period, there may be slight

clouding of consciousness.

• In the post amnestic period, the awareness of

disturbance of memory is present.
Types of Dissociative Amnesia :
1. Circumscribed amnesia- inability to
recall all the personal events during a
circumscribed period of time.

2. Selective Amnesia- Inability to recall only

some selective personal events during
that period while some other events
during that period may be recalled.
3.Continuous amnesia- Inability to recall all
personal events following the stressful event,
till the present time.

4.Generalized amnesia: Inability to recall the

personal events of the whole life.
 Dissociative Fugue

– Sudden onset and usually occurs in presence of

severe stress .

– During the episode, the person adopts a new

identity with complete amnesia for the earlier life.

– The termination is abrupt and is followed by amnesia

for the episode, but with recovery of memories of
earlier life.
Dissociative Identity Disorder

– In this dissociative disorder, the person is

dominated by two or more personalities, of
which only one is being manifest at a time.

– Usually one personality is not aware of the

existence of the other i.e. there is an amnestic
barrier between the personalities.
Dissociative Identity Disorder
Conversion Disorder
 Conversion Disorder
– In conversion disorder, physical symptoms that
resemble those of a nervous system (neurologic)
disorder develop.

– The symptoms are commonly triggered by mental

factors such as conflicts or other stressors.

– Sudden onset.

– An arm or leg may be paralyzed, or people may lose

their sense of touch, sight, or hearing,
convulsions…………
– A clear relationship between the stressor and
development of symptoms.

– Patient does not intentionally produce the

symptoms.
Difference between Epileptic seizures &
Dissociative/conversive convulsion

Clinical points Epileptic seizures Dissociative

convulsion
1.Attack Pattern Known clinical Absence of known
pattern clinical pattern
2.Place of Any where Usually indoors or
occurrence at safe place
3.Time of day Any time. can Never occur
occur during sleep during sleep
4.Tongue bite Usually Present Usually absent
Difference between Epileptic seizures &
Dissociative/conversive convulsion

5. Incontinence of Can occur Very rare

urine & feces

6. Amnesia Complete Partial

7. Neurological sign Present Absent

8. Post attack Present Absent

confusion
Etiology-Psychoanalytical theory

– According to this theory, conversion disorder is

caused by suppression of intrapsychic conflict
and conversion of anxiety into a physical
symptom.

– The conflict is between an impulse and the

prohibitors against it’s expression.

– The symptoms allow partial expression of the

forbidden wish or urge.
– The symptoms also allow patient to
communicate that they need special
consideration and special treatment.

– Such symptoms may function as a

nonverbal means of controlling or
manipulating others by subconscious
mind.
 Treatment of Dissociative Disorder
& Conversion Disorder
Behaviour Therapy:
Since the symptoms of dissociative &
conversion disorders can be increased with
attention, the symptoms should not be focused
on.

These patients should be treated as normal,

and not encouraged to stay in a sick-role. Any
improvement in symptomatology should be
actively encouraged.
 Treatment of Dissociative Disorder
& Conversion Disorder
 When there is a sudden, acute symptom, its prompt
removal may prevent habituation and future disability.

 This may be achieved by one of the following methods:

i. Strong suggestion for a return to normalcy.

ii. Aversion therapy (ammonia; aversive electric stimulus;

pressure just above eye balls or tragus of ear; closing
the nose and mouth) are occasionally employed
carefully in resistant cases.
 Treatment of Dissociative Disorder
& Conversion Disorder
 Psychotherapy with Abreaction
 Abreaction is bringing the hidden conflicts-
thoughts, memories to the conscious level for
the first time. This may be achieved by:

i. Hypnosis.

ii. Intravenous thiopentone or diazepam:

 Treatment of Dissociative Disorder
& Conversion Disorder

-The aim of abreaction with IV thiopentone is- to

make the conflicts conscious and to make the
patient more suggestible to therapist’s advice.

-Once the conflicts have become conscious and

their affects (emotions) have been released, the
conversion or dissociative symptom disappears.
 Treatment of Dissociative Disorder
& Conversion Disorder
 Supportive Psychotherapy
 Supportive psychotherapy is needed especially when
the conflicts (and the current problems) have become
conscious and have to be faced in routine life.

 Drug Therapy
 Drug treatment has a very limited role in these
disorders (apart from the use of IV thiopentone, amytal
or diazepam in abreaction). A few patients have
disabling anxiety and may need short-term
benzodiazepines.
Somatoform Disorder
Somatoform Disorder

‘Soma’ means ‘body’ and Somatoform

disorder involves patterns in which individuals
complaint bodily symptoms that suggest the
presence of medical problems, but for which no
organic basis can be found that satisfactorily
explains the symptoms.
– Such individuals are typically preoccupied
with their state of health and with various
presumed disorders or diseases of bodily
organs.

– They persistently request for investigations

and treatment despite repeated assurances
by the treating doctors.
Categories of Somatoform Disorder
according to ICD-10
 Somatization Disorder

 Hypochondriasis
 Somatoform autonomic dysfunction
- Hyperventilation Syndrome
- Irritable Bowel Syndrome
- Premenstrual Syndrome
 Persistent Somatoform Pain Disorder

 Other somatoform disorder

Somatization Disorder
– Multiple somatic symptoms in the absence of any
physical disorder.

– Symptoms are recurrent and chronic. At least 2 years

duration is required for diagnosis.

– There is frequent change of treating physicians.

– Persistent refusal to accept the advice or

reassurance of several doctors that there is no
physical explanation for the symptoms.
 The symptoms are vague, presented in a dramatic
manner and involve multiple organ systems.

 The common symptoms include-

 Gastrointestinal – abdominal pain, nausea, vomiting,

regurgitation
 Abnormal skin sensations like numbness, tingling,
burning
 Sexual and menstrual complaints like menorrhagia,
dyspareunia.
• Causes-

– Familial history of illness

– Relation with Histrionic personality

disorder (attention seeking attitude, Self-
dramatization)
 Treatment
• Supportive psychotherapy

• Behavior modification

• Relaxation therapy- yoga, meditation

• Drug therapy- Benzodiazepines,

antidepressants.
 Hypochondriasis

 Persistent preoccupation with a fear or

belief of having one or more serious
disease, based on minor physical
abnormality.

 Duration is at least six months for diagnosis

 Features
– Complete physical examination and investigations do not
show presence of any significant abnormality.

– The fear or belief persists despite assurance or after

showing normal reports to the patient.

– The fear or belief is not a delusion. The patient may agree

regarding the possibility of his exaggerating the graveness
of situation, at that time (insight present).

– The patient tends to change the physician frequently, in

order to get investigated again.
 Treatment
– Supportive psychotherapy

– Treatment of associated anxiety and

depression.
Categories of Somatoform Disorder
according to ICD-10

Somatization Disorder

Hypochondriasis
Somatoform autonomic dysfunction
- Hyperventilation Syndrome
- Irritable Bowel Syndrome
- Premenstrual Syndrome
Persistent Somatoform Pain Disorder

Other somatoform disorder

Somatoform autonomic dysfunction

• According to ICD-10, in this disorder, symptoms

are presented by the patient as if they were due
to a physical disorder of an organ system that is
predominantly under autonomic control.

1. Hyperventilation Syndrome

2. Irritable Bowel Syndrome

3. Premenstrual Syndrome
1. Hyperventilation syndrome

The hyperventilation syndrome is characterized

by a ‘habit’ of hyperventilation which becomes
particularly marked in the presence of
psychosocial stress.
• In mild form- excessive fatigue, chest pain,
palpitation, sweating, headache and feeling
of light headedness.

• In severe hyperventilation- carpopedal

spasm, paresthesias and loss of
consciousness.

These symptoms are produced by

hypocapnia.
 Treatment
1. Relaxation techniques: Progressive muscle
relaxation, hypnosis, yoga….

2. Relaxed breathing techniques

3. Breathing-in-bag technique

4. Treatment of underlying anxiety or depression

antidepressants and/or benzodiazepines
2. Irritable Bowel Syndrome
The principal abnormality in IBS is a disturbance
of bowel mobility, which is modified by
psychosocial factors. Pts are usually experience-

– Disturbance of bowel motility.

– Abdominal pain, discomfort or cramps.
– Alteration of bowel habit (diarrhea or
constipation)
– A sensation of incomplete evacuation.
 Treatment
 Supportive psychotherapy

 Identification of current life stressors, environmental

manipulation, and learning of coping skills aimed at
dealing with stressors

 Anti-anxiety and antidepressant medication may be

helpful

 Symptomatic management
 3. Premenstrual Syndrome
– Variety of physical, psychological and behavioral
symptoms occurring in the second half of menstrual
cycle.

– The symptoms start after a few days of ovulation,

reach a peak about 4-5 days before menstruation
and disappears usually around menstruation.

– The period between menstruation and next

ovulation is normal.
Characterized by-
- Irritability

- Depression

- Crying spells

- Restlessness

- Headache

- Fatigue
 Treatment
Supportive psychotherapy

Hormonal treatment: Danazol, GnRH agonist:

Buserelin

In resistant cases, other drugs such as lithium,

pyridoxine, antidepressants and anti-anxiety
agents
Persistent Somatoform Pain
Disorder

– Persistent, severe and distressing pain

which is excess of what is expected from
the physical findings or inconsistent with
the anatomical disturbance

– Doctor shopping is very common.

 Treatment
1.The patients usually refuse psychiatric intervention;
therefore treatment is often managed by the treating
physician.

2. Drug therapy should be avoided if possible, as the risk

of drug abuse is quite high.

3.In the absence of other modes of successful

treatment, a supportive relationship with a physician
will prevent doctor-shopping and provide relief.