Transcript Neurotic Disorders MRCPsych II, GA Module

Neurotic Disorders
MRCPsych II, GA Module
Dr. Naresh K. Buttan
M.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec12 (2) Approved
Consultant Psychiatrist- HTT & Glenbourne; PCH-CIC
Hon’ Fellow- PCMD, Plymouth Locality Psychiatry Lead & AT-PMS
TPD- CT, Health Education-South West
E-mail: [email protected], [email protected]
Neurotic
DisordersScene
Setting
RCPsych ILOs
 1, 2: Identify, diagnose & formulate
 3, 4, 5: Investigate, Manage & Refer
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Concept- Evolution of neurosis/ anxiety
Epidemiology, C/F, Diag. Criteria, D/D
Aetiology & Management Principles
3 case studies- 4 groups, 3 minutes on each case,
correct answer- 10 points, wrong – 0
• 2 scorers, 4 major mental disorders
• MCQs- Shout 1st & 10 for right & - 5 for wrong
Neurosis/Anxiety- Concept
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Neurosis/ Anxiety ?
Worry (N, Webster/ Oxford Dictionary)
Stress
Normal vs. abnormal
State vs. trait
Episodic vs. Pervasive
Situational vs. Generalized
Internal (Active) vs. Reactive
Anxiety (Neurotic) Disorders: Relevance
• Prevalence: General Population
Disorder
Prev. 6/12 Rates % Lifetime Rates %
Schizophrenia
Affective Dis.
0.9
5.8
1.5
8.3
D & A dis
Anxiety Dis
6.0
8.9
16.4
14.6
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‘Symptoms- common in gen. population
High Comorbidities
May present with physical symptoms
Proper recognition for appropriate treatment
Management- combined approach
Anxiety (Neurosis)- History
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Greek: 3 Humors
Dark age: spirits/ divine punishments
‘Hysteria’ – Hippocrates (15th-16th Cent.)
‘Neurosis’- William Cullen (1777)
‘Studies in Hysteria’- S. Freud (1895)
Psychoanalytical - repression, topological mind,
fixations, defense mechanisms
• WW I → ‘Emotional’ vs. ‘Physical’, ‘Conversion
Hysteria’ or ‘Phobic Neurosis’
Anxiety (Neurosis)- History…..
• ‘Emergency Reaction’- Waltor Canon (1920s)- ‘Fight
or Flight’ response via ANS
• “Conditioning’- John Watson (1930s)- traumatic
learning situations
• ‘Instrumental Conditioning’- Mowrer (1940s)‘reinforcers’ & ‘desensitization’
• Canon Bard Theory (HPA axis)
• Tranquilizers- Benzos, Antidepressants
• Imaging: Frontal cortex & B/L Caudate in OCD,
Temporal lobes- Panic →TLEs
Anxiety (Neuroses)- Present
• Early Adverse
Life
Experiences.
• Genetic
Predisposition
Bio. Vulnerabilty
Personality/
Temperament
Bio. Changes in
Brain Fn.
Anxiety symptoms
Traumas/ SLEs
D&A
Physical
Illnesses
Anxiety Disorders
GAD
Panic
Phobic
Simple/ Sp.
Natural/ Environmental
Blood/ Injury/ Injection
Animal
Other
PTSD
OCD
Compd./Gen.
Agoraphobia
Social Phobia
Case 1
• 35 YO single female, working as receptionist,
presents with 12/12 h/o of vague body aches,
headaches, wt loss, initial insomnia, worried
about anything & everything, lethargy, no
sadness, cold sweats, numbness, using alcohol as
coping.
• No past/family history of mental illness
• Personal History: Uneventful birth, early
development, schooling.
• Lost 3 sibs in RTA during her college days
Case 1….
• Parents elderly in care home
• Previous relationship ended 18/12 ago due to her
own worries & frequent arguments
• Job cuts in work place, thinks she may lose her job
despite frequent reassurances from boss
• No D&A issues, GPE- NAD, ↑sed HR
• MSE: Tense, edgy, tremors, sweaty, ‘fear of dying’, no
delusions/ hallucinations/suicidal thoughts, MMSE27/30-recall*
Case 1…
• Gp 1: Diagnoses/ differentials
• Gp 2: Aetiology
• Gp 3: Treatments
• Gp 4: Risks/prognosis
Generalised Anxiety Disorder
• Essence: generalised free floating persistent anxiety
• Epidemiology: 6/12- ECA: 2.5- 6.4%, Early onset (Av 21),
F>M, Single, Unemployed.
• Aetiology:
a) Genetic: Heritability 30%
b) Neurobiological: ANS arousal, loss of regulatory control
of cortisol (HPA axis), abnormal neurotransmitters
(↓GABA, 5HT dysregulation,)
c) Psychological: Unexpected -ve SLEs (death, loss, rape),
chronic stressors; conditioning, reinforcers, failed
repression, loss of object /attachment
Generalised Anxiety Disorder….
Diagnostic criteria: ICD 10-: Pervasive anxiety & at least 4
(min 1 from autonomic) of:
a. ANS- palpitation, sweating, trembling, dry mouth
b. Physical: SOB, choking, chest pain, nausea
c. MSE: dizziness, DPR/DR, LOC, fear of dying
d. General: hot flushes, numbness, tingling
e. Tension: muscle tension, aches/ pains, restlessness,
edgy, lump in throat, dysphagia
f. Other: startle reaction, blank mind, irritability,
insomnia
Generalised Anxiety Disorder…..
Comorbidity/ D/D:
• Other anxiety disorders
• D & A abuse & withdrawal
• Medications (CVS: AntiHT, antiarrhythmics, RS:
brochodilators,CNS:
anticholinergics,AEDs,
DA,
Psychiatric: ADs, NLs, antabuse reaction, bezo
withdrawal)
• GMCs (CVS: arrhythmias, MVP, CCF; RS: Asthma,
COPD, PE; CNS: TLE, VBI; Endocrine: Hyperthyroidism,
hypoparathyroidism, ↓sed BM, phaeochromocytoma
Misc: Anaemia, porphyria, SLE, pellagra, Carcinoid)
GAD- Treatments
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Psychological: less effective than in other anxiety disorders,
CBT useful- education, cognitive remediation. BT- exposure,
relaxation, control of hyperventilation.
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Physical: ECT/ Psychosurg.- rare (severe intractable)
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a)
b)
c)
d)
Pharmacological: directed towards symptom domains:
Psychic- buspirone
Somatic- benzos
Depressive- TCAs, SSRIs, SNRIs, Mirtazepine, MAOIs
ANS/CVS- β blockers
Case 2
• 35 YO married unemployed male with h/o
ADS, presents with 12 yrs h/o cleaning &
checking rituals, feeling hopeless &
suicidal, homebound.
• Prev. treated with SSRIs, Antipsychotics partial response, disengaged from CBT
• N. birth/early dev/schooling, graduated,
worked as Real Estate manager till 25,
unemployed & on DLA
Case 2…
• F/H/o: Depression in mom, strict parents- high
expectations, 3 sibs-all perfectionists
• O/E:GPE- NAD, rough skin, mildly ↑sed AST/ALT
• MSE: Pressured, agitated, restless, doubts re
contamination & need to check everything, no
delusions/hallucinations, fleeting suicidality, no
plans, MMSE- couldn’t complete as had to check
frequently
Case 2
• Gp 2: Diagnoses/ diffrertials
• Gp 3: Aetiology
• Gp 4: Treatments
• Gp 1: Risks/prognosis
Obsessive Compulsive Disorders
• Essence: a common chronic condition with obsessions &/or
compulsions causing severe distress .
• Clinical features:
Obsessions
a)
b)
Recurrent,
persistent,
intrusive,
irrational
thoughts/ impulses/ images
causing severe anxiety
Person attempts to ignore/
suppress/ neutralize with
some other thoughts or
actions.
Ownership
maintained- not alienation
Compulsions
a)
b)
Repetitive behaviours/
mental acts in response to
obsession or according to
strict rules
Behaviours/ mental acts
aim at preventing/ reducing
distress or dreaded
outcomes
OCD….
• Types: Check(63%), wash(50%), contamination (45%),
doubt(42%), bodily fears (36%), count (36%), symmetry
(31%), aggressive (28%)
• Epidemiology: Age- 20yrs, F=M, Prev. – 0.5-2%
• Associations: Cluster C (40%), anankastic traits (5-15%),
Schiz. (5-45%), Sydenham chorea (70%), TS
• Comorbidity: Dep.(50-70%), D & A, Soc. phobia, panic
dis, ED, tic disorder (40% Juvenile OCD), TS
• D/D: Normal worries, anankastic PD, schizophrenia,
phobias,
depression,
hypochondriasis,
BDD,
trichotillomania.
OCD- Mx…..
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Psychological:
Supportive: valuable, family, groups
BT: ERP, Thought stopping (ruminations)
CBT: Not proven effective, RET
B Pharmacological:
a) SSRIs: 1st line, lag period (12 weeks), long term
b) TCAs (CMI)/ MAOIs
c) Augmentation: buspirone, antipsychotics, lithium
C Physical: ECT- suicidal, Psychosurgery- intractable (treatment
resistant- 2 Ads, 3 Combinations, ECT & BT)- streotactic
cingulotomy (65% success)
OCD- Aetiology
Theories:
1) Neurochemical: 5HT dysregulation, 5HT/DA interaction
2) Immunological: CMI (against basal ganglia peptides)
3) Imaging: CT/MRI- B/L reduction in caudate size PET/SPECThypermetabolism in orbitofrontal gyrus & BG
4) Genetic: MZ: DZ= 50-80:25%, 3-7% 1st degree relatives
5) Psychological: Defective arousal & / or inability to control
unpleasant, obsessions -conditioned stimuli, compulsionsreinforced learned behaviours
6) Psychoanalytical: regression, isolation, undoing & reaction
formation
OCD…….
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Course: sudden onset, fluctuating/ chronic,
Outcome:
20-30%
significant,
40-50%
moderate, 20-40% chronic/worsening.
• Prognostic factors:
A. Poor: giving in, longer duration, early onset,
bizarre compulsions, symmetry, comorbid
depression, PDs (schizotypal),
B. Good: good premorbid social & occupational
level, a precipitating event, episodic symptoms.
Case 3
• 22 YO single PG student presents with 3/12
h/o nightmares, flashbacks, panic attacks,
fearfulness, insomnia, poor appetite, loss
of conc. & enjoyment.
• Was mugged & date raped 4/12 ago, police
arrested the culprits & she gave witness.
• N. Birth/early dev/schooling/peers/ good
grades
• CSA: by elderly neighbour 7-8 yrs age
Case 3…
• No past/ family history
• O/E: GPE- NAD, tremors & ↑sed HR
• MSE: Anxious, guarded, slow to warm up,
describes flashbacks of incidents, low self
esteem, no depressive/psychotic
symptoms/signs, willing to engage in
treatment.
Case 3…
• Gp 3: Diagnoses/ differentials
• Gp 4: Aetiology
• Gp 1: Treatment
• Gp 2: Risks/prognosis
Post Traumatic Stress Disorder (PTSD)
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Essence: Severe psychological disturbance following a trauma,
involuntary re-experiencing with symptoms of hyperarousal,
avoidance & emotional numbing.
Symptoms/Signs: Onset within 6/12 (ICD10) of trauma, at least
1/12 with clinically significant distress or impairment in social,
occupational or other important areas; 2 or more ‘persistent
symptoms of ↑sed psychological sensitivity & arousal:
Initial/ middle insomnia
Irritability/ anger outbursts
Poor concentration
Hypervigilance
↑sed startle response
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PTSD- Aetiology
Psychological: ‘Remodeling of Underlying Schemas’requires holding of trauma experience in ‘active
memory’ (working through). Dissociation protects
from being overwhelmed.
Biological: Neurophysiological changes → permanent
neuronal changes (chronic/ persistent stress/
reliving). Neurotransmitters- NA/ 5HT/ GABA/
Endogenous opioids / glucocorticoids.
Neuroimaging: ↓sed R hippocampal vol.,
dysfunction of amygdala & associated projections↑sed fear response
Genetic: Higher concordance in MZ > DZ twins
PTSD…..
• Epidemiology: Risk of PTSD (20-30%), Median(8-13%),
Lifetime prevalence-7.8%, F: M= 2:1, Cultural
differences +
• Risk factors: Vulnerability: low education, low SE class,
Afro-Carribean /Hispanic, Female, low self esteem /
neurotic traits, past/ family h/o psychiatric problems,
previous traumas (CSA).
• Comorbidity: Depression, mood disorder, D & A,
somatisation disorders.
• D/D: ASR/ D, Enduring personality change, adjustment
dis., other anxiety dis., depression, mood disorder, OCD,
schiz., D & A.
PTSD- Management
• Psychological:
a) CBT: TOC- education, self monitoring, anxiety
management, exposure, cognitive restructuring
b) EMDR: Voluntary multisaccadic eye movements
c) Psychodynamic: meaning & work through
• Phramacological: limited evidence, for comorbid
1) Depression: SSRIs/TCAs/MAOIs
2) Anxiety: Benzo/buspirone/ ADs
3) Intrusive thoughts: CBZ, Li, Fluvoxamine
PTSD- Course & Outcome
50% recover in 1 yr, 30% chronic course
Outcome dependent on initial symptom
severity
Recovery helped by: good social support,
absence of maladaptive coping, no further
traumas, no D&A/Forensic
MCQ 1
Q1. The ‘the sense of impending doom always’
is the main feature of which of the following:
A.Mania
B.Alcohol withdrawal
C.Generalized Anxiety Disorder
D.Depression
MCQ 2.
Q 2: Obsession is:
A. False, firm unshakable belief out of social/
cultural context
B. Own, Irrational, Repetitive, Intrusive
egodystonic belief/ impulse/ image
C. Irrational fear of a specific situation/object
causing avoidance
D. Perception without an external stimulus
MCQ 3.
Q 3: The main feature of PTSD is:
A. Own, Irrational, Repetitive, Intrusive ego
dystonic belief/ impulse/ image
B. Reliving traumas with resultant arousal,
numbing and avoidance associated with
trauma
C. Perception without an external stimulus
D. Repetitive acts/thoughts to neutralize
anxiety caused by obsessions
Answers
• Q1. C
• Q 2. B
• Q 3. B
Further reading
• Oxford Textbook of Psychiatry, 5th Ed, Gelder M,
Harrison & Cowen P., Oxford University Press 2006
• ICD 10- Clinical Description & Diagnostic Guidelines,
WHO 1994
• DSM IV-TR- A Clinical Guide to Differential Diagnosis,
APA 1994, Revised 2004
• The Maudsley Prescribing Guidelines, 10th Ed, Taylor
D, Paton C & Kapur S, Informa Healthcare 2009
Thank You & Best Wishes !