NEUROTIC

DISORDERS
NEUROTIC DISORDERS

 The terms neurosis and psychosis are currently

not widely used.
 Mixtures of symptoms, especially anxiety and
depressive ones are common in these
disorders
 About one fourth of the population in
developed countries will suffer from neurotic
disorders during its lifetime course.
 With the exception of social phobia their
frequency is higher in women than in men.
CLASSIFICATION
 ‘Neurotic, Stress-related And Somatoform
Disorders have been classified into the following
types:
1. Phobic anxiety disorder,
2. Other anxiety disorders
3. Obsessive compulsive disorder.
NEUROTIC, STRESS-RELATED AND
SOMATOFORM DISORDERS (F40-F48)
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive-compulsive disorder
F43 Reaction to severe stress, and adjustment
disorders
F44 Dissociative [conversion] disorders
F45 Somatoform disorders
F48 Other neurotic disorders
ANXIETY DISORDERS
 Anxiety disorder is the most commonest psychiatric
symptom in clinical practice.

 Anxiety is a ‘normal’ phenomenon characterized by a

state of apprehension or unease arising out of
anticipation of danger.

 Normal anxiety becomes pathological when it causes

significant subjective distress or impairment in
functioning of the individual.
Types of anxiety:

▪ TRAIT ANXIETY: it is a habitual tendency to be

anxious in general and is exemplified by ‘I often feel
anxious’.

▪ STATE ANXIETY:it is the anxiety felt at the present

moment exemplified by ‘I feel anxious now’.

 Persons with trait anxiety often have episodes of state

anxiety.
SYMPTOMS OF ANXIETY
 ❑ PHYSICAL SYMPTOMS:

▪ Motoric symptoms: tremors, restlessness, muscle

twitches, fearful facial expression.

▪ Autonomic and visceral symptoms: palpitations,

tachycardia, sweating, flushes, dry mouth, frequency
and hesitancy of micturation, dizziness, diarrhea.
 PSYCHOLOGICAL SYMPTOMS:
• Cognitive symptoms: poor concentration,
distractibility, vigilance or scanning, hyperarousal.

• Perceptual symptoms: derealization,

depersonalization

• Affective symptoms: diffuse, unpleasant, vague sense

of apprehension, fearfulness, inability to relax,
irritability.

• Other symptoms: insomnia, exaggerated startled

response.
FEAR VS. ANXIETY
 Known in origin  Unknown or vague
 Definite  Indefinite

 External source  Internal in Origin

 Alerting signal  Alarming signal

 Non-conflictual  Conflictual
F40 PHOBIC ANXIETY DISORDERS

F40 Phobic anxiety disorders

F40.0 Agoraphobia
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
 THEORIES OF
PATHOLOGICAL
ANXIETY
ETIOLOGY OF ANXIETY DISORDERS
 The etiology of anxiety disorders is not exactly
known.

 Nongenetic factors, such as various stressful life

events during early or later stages of ontogenesis
(earlier stages of behavioral maturity) were
thought to be even more important.

 The role of CO2 in the etiology of panic disorder is

seriously discussed.
1. Psychological theories:
A- Psycho-dynamic theory:

 anxiety is signal that something is disturbing the

internal psychological environment.

 This signal anxiety arouses the ego to take defense

mechanism in form of repression.

 When repression fails other secondary defense

mechanism comes to action.

 Anxiety occurs when secondary defense mechanism

are not activated.
B- BEHAVIORAL THEORIES: Anxiety is a conditioned
response to specific environmental stimuli. It also result from
imitation of anxiety responses of other people ( social
learning theory)
 An example of classical conditioning is a boy who is anxious in
the presence of his abusive mother; he then generalizes this
anxiety as a response to all women.
 Conditioning can be reversed through the influence of safe and
loving female friends and significant others
PAVLOV'S DOG
SKINNERS RAT
 C- COGNITIVE BEHAVIOURAL THEORY

Selective information processing ( more attention

to threat related information),cognitive distortion,

negative automatic thought & perception of

decreased control over both internal and external

stimuli.
2. Biological theories:

A- Autonomic nervous system: stimulation of autonomic

n.s. causes certain symptoms ;like cardio-vascular
symptoms, muscular, GIT, &respiratory

B- Neurotransmitters: the three major NT associated

with anxiety on the basis of animal studies & response
to drugs are: norepinephrine , serotonin(5HT), and
Gamma-amino-butyric acid (GABA)
 C- BRAIN IMAGING STUDIES
:

STRUCTURAL: CT & MRI have found many abnormalities in the

brains :increase in the size of cerebral ventricles , specific
deficits in the right temporal lobe, abnormal function of the right
cerebral hemisphere but not the left which means cerebral
asymmetry

FUNCTIONAL: PET, SPECT &EEG of patients with anxiety

disorders have reported abnormalities in the frontal cortex , the
occipital & temporal areas and other regions
Neuro-anatomical considerations: The raphe
nucleus and the locus coerulus which are the
main areas important in anxiety projects with areas
in the limbic system and cerebral cortex
D- Genetic studies:

 15-20% of first degree relatives

 Higher rate in monozygotic twins

PHOBIC ANXIETY DISORDERS

 Phobia is defined as an irrational fear of a specific object,

situation or activity, often leading to persistent
avoidance of the feared object, situation or activity

The common types of phobias are:

 1. Agoraphobia,

 2. Social phobia, and

 3. Specific ( Simple) phobia.

 Phobic anxiety fluctuates from mild uneasy to
terror.

 The individual’s concern may focus on individual

symptoms such as palpitations or feeling faint
and is often associated with secondary fears of
dying, losing control, or going mad.

 The anxiety is not relieved by the knowledge that

other people do not regard the situation in
question as dangerous or threatening
AGORAPHOBIA
 Agoraphobia“ - the fear of

marketplace(Open places).

 Agoraphobia includes various phobias

embracing fears of leaving home: fears of

entering shops, crowds, and public

places, or of traveling alone in trains,

buses, underground or planes.

 The lack of an immediately available exit

is one of the key features of many

agoraphobic situations.
 The avoidance behaviour causes sometimes that
the sufferer becomes completely housebound.

 Most sufferers are women. Onset - early adult

life.

 The lifetime prevalence - between 5—7%.

 High co-morbidity with panic disorder; depressive

and obsessional symptoms and social phobias
may be also present.
AGORAPHOBIA

Anticipative Phobic
Anxiety Anxiety

Specific Situation
 SOCIAL PHOBIAS
 Clinical picture - fear of scrutiny by other
people in comparatively small groups leading to
avoidance of social situations

 The fears may be

 Discrete - restricted to eating in public, to be
introduced to other people, to public speaking, or to
encounters with the opposite sex
 Diffuse - social situations outside the family circle.
 Direct eye-to-eye confrontation may be stressful.

 Low self-esteem and fear of criticism.

 Symptoms may progress to panic attacks.

 Avoidance - almost complete social isolation.

 Usually start in childhood or adolescence.

 Estimation of lifetime prevalence - between 10-13 %.

 It is equally common in both sexes.

 Secondary alcoholism
SOCIAL PHOBIAS

Anticipative
Phobic
Anxiety
Anxiety

Social Stress
SPECIFIC (ISOLATED) PHOBIAS
1. Fears of proximity to particular animals
 spiders (arachnophobia)

 insects (entomophobia)

 snakes (ophidiophobia)

2. Fears of specific situations such as

 heights (acrophobia)

 thunder (keraunophobia)

 darkness (nyctophobia)

 closed spaces (claustrophobia)

3. Fears of diseases, injuries or medical examinations
 visiting a dentist

 the sight of blood (hemophobia) or injury (pain —

odynophobia)

 the fear of exposure to venereal diseases

(syphilidophobia) or AIDS-phobia.

 Usually arise in childhood or early adult life and can

persist for decades if they remain untreated.

 Lifetime prevalence - between 10-20%.

 ETIOLOGY
Psychoanalytical theory
Using repression and displacement defense mechanism
Unconscious fears may also be expressed in a symbolic
manner as phobias.
Behavioral theory: Conditioned reflex,
Direct learning or imitation (modeling)
Cognitive theory: anxiety is the product of faulty
cognitions
Biological Theories
 Genetic theory

 epinephrine imbalance
 Life Experiences:
Example
■ A child who is punished by being locked in a
closet develops a phobia for elevators or other closed
places.
■ A child who falls down a flight of stairs develops
a
phobia for high places.
■ A young woman who, as a child, survived a plane
crash in which both her parents were killed has a
phobia of airplanes.
TREATMENT OF SPECIFIC PHOBIA

 A. The primary treatment is behavioral

therapy:
A commonly used technique is
systemic desensitization, consisting of
gradually increasing exposure to the feared
situation, combined with a relaxation technique
such as deep breathing.
Flooding
Modeling
Exposure and response prevention
 B. Beta-blockers may also be useful prior to
confronting the specific feared situation.
TREATMENT OF SOCIAL PHOBIA

 A. SSRIs, such as paroxetine 20-40 mg/day or sertraline 50-

100 mg/day, are first-line medications for social phobia.
Venlafaxine 75-225mg/day may also be used.

 Benzodiazepines, such as clonazepam 0.5-2 mg per day, may

be used if antidepressants are ineffective

 B. Social phobia with performance anxiety (for specific

situations known to be anxiety provoking) responds well to
beta-blockers, such as propranolol. The effective dosage can
be very low, such as 10- 20 mg qid. Or 20-40 mg given 30-60
minutes prior to the anxiety provoking event
 C. Cognitive/behavioral therapies are effective
and should focus on cognitive retraining,
desensitization, and relaxation techniques
Combined pharmacotherapy and cognitive or
behavioral therapies is the most effective
treatment

 D. Group psychotherapy (Learn how to interact

with other people)
F41 OTHER ANXIETY DISORDERS
F41 Other anxiety disorders
F41.0 Panic disorder (episodic paroxysmal anxiety)
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
OTHER ANXIETY DISORDERS

 Manifestations
of anxiety are also the major
symptoms of these disorders, however, it is not
restricted to any particular environmental
situation.
PANIC ANXIETY
DISORDER
 ‘Panic’ derives from the Greek god Pan, who was in the habit of
frightening humans and animals ‘out of the blue’

 The essential features are recurrent attacks of severe anxiety

(panic attacks) which are not restricted to any particular
situation or set of circumstances.

 Reach a peak of intensity in about 10min, and generally do not

last longer than 20–30min (rarely over 1hr).

 Sometimes attacks may occur during sleep (nocturnal panic

attacks)
 EPIDEMIOLOGY

 The estimation of lifetime prevalence moves

between panic disorder averages 7 to 9 per cent.

 highest peak incidence at 15–24yrs and 45–

54yrs

 Women are 2–3 times more likely to be affected

than men.
 RISK FACTORS

 being widowed,
 divorced, or separated;

 living in a city;

 limited education;

 early parental loss;

 physical or sexual abuse.

SYMPTOMS OF A PANIC ATTACK (IN ORDER OF
FREQUENCY)

● Palpitations
● Tachycardia
● Sweating and flushing
● Trembling
● Dyspnoea
● Chest discomfort
● Nausea
● Dizziness or fainting
● Fears of an impending medical emergency
● Depersonalization and derealisation (feeling
detached from oneself or one’s surroundings).
 Frequent and predictable panic attacks produce
fear of being alone or going into public places.

 The afflicted persons used to think that they got

a serious somatic disease.

 The course of panic disorder is long-lasting and is

complicated with various comorbidities, in half of
the cases with agoraphobia.
AETIOLOGY
 The cause of the first panic attack is uncertain.
1 Genetics. first-degree relatives of those with
the disorder are seven to eight times higher than
average.
2 The biochemical hypothesis suggests that
panic disorder is due to an imbalance in
neurotransmitter (Serotonine, adrenergic, GABA,
Cholecystokinin–pentagastrin) activity in the
brain.
3 The cognitive hypothesis: patients with panic
disorder more often have fears concerning physical
symptoms of anxiety.
AETIOLOGY
 Infusion of chemicals (such as sodium lactate,
isoproterenol and caffeine),
 ingestion of yohimbine and inhalation of 5% CO2
can produce panic episodes in predisposed
individuals.
 MAOIs before the lactate infusion protects the
individual(s) from panic attack.
MANAGEMENT PLAN FOR PANIC DISORDER
Assessment
 Make a diagnosis and detect any co-morbid
depressive disorder
General measures
 Hyperventilation management: paper bag
breathing
● Psychoeducation
● Problem-solving techniques and relaxation
● Manage hyperventilation
Psychological treatment
● Self-help books, computerized cognitive
behavioural therapy
● Cognitive behavioural therapy
 Jacobson’s progres sive relaxation technique,
yoga, pranayama, self-hypnosis, and meditation

Pharmacotherapy
● Antidepressants are drug of choice : small doses
of anti depressants, usually SSRIs (e.g. fluoxetine).
 GENERAL ANXIETY DISORDER


 Symptoms: continuous feelings of nervousness, trembling, muscular

tension, sweating, lightheadedness, palpitations, dizziness, and
epigastric discomfort.
 Fears that the patient or a relative will shortly become ill or have an
accident are often expressed, together with a variety of other worries
and forebodings.
EPIDEMIOLOGY

 3.1%- lifetime prevalence

 lowest in 18–29yrs (4.1%)

 highest 45–59yrs (7.7%)

 60+yrs (3.7%);

 stressful event; single, unemployed

 This disorder is more common in women, and

often related to chronic environmental stress.
 Its course uses to be fluctuating and chronic
connected with symptoms of frustration, sadness
and complicated with abuse of alcohol and other
illicit drugs.

AETIOLOGY
Generalized psychological vulnerability:
• Diminished sense of control—trauma or
insecure attachment to primary caregivers, leading
to intolerance of uncertainty.
• Parenting—overprotective or lacking warmth,
leading to low perceived control over events.
• Specific psychological vulnerability: stressful
life events—trauma (e.g. early parental death, rape,
war) and dysfunctional marital/family
relationships.
MIXED ANXIETY AND DEPRESSIVE DISORDER

 Symptoms of both anxiety and depression

are present, but neither of symptoms,
considered separately, is sufficiently severe to
justify a diagnosis of depressive episode or
specific anxiety disorder.

 Some autonomic symptoms, such as tremor,

palpitations, dry mouth, stomach churning,
must be present.
CLINICAL MANAGEMENT OF
ANXIETY DISORDERS
 Treatment of anxiety disorders:
 various psychotherapeutic techniques
 cognitive-behavioural therapy (CBT)
 psychodynamic approaches

 psychopharmacotherapy
 benzodiazepines (alprazolam, clonazepam) - for several weeks (potential for
abuse, development of tolerance and addiction)
 Buspirone - little abusive potential; especially GAD, not effective in panic

disorder; longer use is necessary

 beta-blocking drugs - for the short treatment of performance anxiety,

especially somatic symptoms like tremor

 antihistaminic

 various types of antidepressants - SRIs (clomipramine, citalopram,

fluoxetine, fluvoxamine, paroxetitle, sertraline), MOAIs (tranylcypromifle),

RIMA (moclobemide) and SNRI (venlafaxine); well tolerated, no abuse
potential

 .
 Recommendation: to start the treatment with a
brief course of benzodiazepines as well as with
antidepressants for a longer period and
 to combine the drug treatment with various types
of psychotherapy
COMMONLY USED ANXIOLYTICS
Drug Commonly used Elimination
dosage (mg) halftime (hours)
Alprazolam 0.5-6 12-15
Bromazepam 3-15 12
Diazepam 5-30 24-72
Chlordiazepoxide 10-50 24-100
Clobazam 20-30 20
Clonazepam 1-8 34
Clorazepate 15-60 60
Lorazepam 1-4 11-13
Medazepam 10-30 29
Oxazepam 30-90 4-20
Tofizopam 50-300 6
Buspirone 20-30 2-11
Hydroxyzine 300-400 12-20
 NURSING MANAGEMENT
1. ANXIETY (PANIC)
Possible Etiologies (“related to”)
 Unconscious conflict about essential values and
goals of life
 Situational and maturational crises

 [Real or perceived] threat to self-concept

 [Real or perceived] threat of death

 Unmet needs

 [Being exposed to a phobic stimulus]

 [Attempts at interference with ritualistic

behaviors]
Defining Characteristics (“evidenced by”)
 Increased respiration
 Increased pulse
 Decreased or increased blood pressure
 Nausea
 Confusion
 Increased perspiration
 Faintness
 Trembling or shaking
 Restlessness
 Insomnia
 [Fear of dying, going crazy, or doing something uncontrolled
 during an attack]
INTERVENTION
 Maintain a calm, nonthreatening manner while
working.
 Reassure client of his or her safety and security.
This can be conveyed by physical presence of
nurse. Do not leave client alone at this time.ng
with client
 Use simple words and brief messages, spoken
calmly and clearly, to explain hospital
experiences to client.
 Hyperventilation may occur during periods of
extreme anxiety. Allow client to breathe into a
small paper bag held over the mouth and nose.
 Administer tranquilizing medication, as ordered
by physician. Assess medication for effectiveness
and for adverse side effects.
 When level of anxiety has been reduced, explore
with the client possible reasons for occurrence.
 Teach the client signs and symptoms of
escalating anxiety and ways to interrupt its
progression
2. FEAR
Possible Etiologies (“related to”)
 Phobic stimulus

 [Being in place or situation from which escape

might be difficult]
 [Casing embarrassment to self in front of other

Defining Characteristics (“evidenced by”)

 [Refuses to leave own home alone]

 [Refuses to eat in public]

 [Refuses to speak or perform in public]

 [Refuses to expose self to (specify phobic object or

situation)]
 Identifies object of fear
INTERVENTIONS WITH SELECTED
RATIONALES
 Reassure client of his or her safety and security.
 Explore the client’s perception of threat to
physical integrity or threat to self-concept
 Discuss reality of the situation with client in
order to recognize aspects that can be changed
and those that cannot.
 Include client in making decisions related to
selection of alternative coping strategies.
 techniques of desensitization may be employed
INEFFECTIVE COPING
Possible Etiologies (“related to”)
 [Underdeveloped ego; punitive superego]

 [Fear of failure]

 Situational crises

 Maturational crises

 [Personal vulnerability]

 [Inadequate support systems]

 [Unmet dependency needs]

Defining Characteristics (“evidenced by”)
 Inability to meet basic needs

 Inability to meet role expectations

 Inadequate problem-solving

 [Alteration in societal participation]

F42 OBSESSIVE-COMPULSIVE DISORDER
(OCD)

F42 Obsessive-compulsive disorder

F42.0 Predominantly obsessional thoughts or
ruminations
F42.1 Predominantly compulsive acts
(obsessional rituals)
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive-compulsive disorders
F42.9 Obsessive-compulsive disorder,
unspecified
 OBSESSIVE-COMPULSIVE DISORDER (OCD)
 Obsessional thought are ideas, images or impulses that
enter the individual’s mind again and again in a
stereotyped form.
 They are recognized as the individual’s own thoughts,
even though they are involuntary and often repugnant.
 Common obsessions include fears of contamination, of harming other
persons or sinning against God.

 Compulsions are repetitive, purposeful, and

intentional behaviours or mental acts performed in
response to obsessions or according to certain rule that
must be applied rigidly.
 Compulsions are meant to neutralize or reduce discomfort
or to prevent a dreaded event or situation.
 Autonomic anxiety symptoms are often present.
 There is very frequent comorbidity with
depression (about 80%) - suicidal thoughts.
 Obsessive-compulsory symptoms may appear in
early stages of schizophrenia.
 The life time prevalence: 2 - 3%. Equally common
in men and women. The course is variable and
more likely to be chronic.
CLINICAL SYMPTOMS
 Checking (63%), washing (50%),
 contamination (45%), doubting (42%),

 bodily fears (36%), counting (36%),

 insistence on symmetry (31%),

 aggressive thoughts (28%).

 ETIOLOGY
• Genetic factors
• Biological factors
• Psychoanalytic theory
• Behaviour theory
GENETIC FACTORS

 Twin studies have consistently found

a significantly higher concordance
rate for monozygotic twins than for
dizygotic twins.
 Family studies of these patients
shown that 35% of the first degree
relatives of OCD patients are also
affected by the disorder.
BIOLOGICAL FACTORS

• Abnormal levels of the

neurotransmitter, serotonin in individuals
with OCD.
• PET & SPECT have shown increased
metabolism and blood flow in the frontal
lobes, basal ganglia, cingulum of patients
with OCD.
 • CT and MRI studies revealed,
bilaterally decreased size of caudate in
patients with OCD. In some patients,
enlarged basal ganglia can be noted.
PET & SPECT STUDIES
 AETIOLOGY

 Psychodynamic Theory
Isolation of affect: removes the affect from the
anxiety-causing idea. When isolation of affect is
not fully successful
❖ So ideas thus weakened but remains still in
consciousness
❖ But affect is free but attached itself to neutral
stimuli by symbolic association.
Undoing: leads to compulsion
Thus this theory explains OCD by regression to
anal sadistic phase of development with the use
of isolation, undoing and displacement
PSYCHOANALYTIC THEORY

• Individuals with OCD have weak, under developed

egos.
• Clients with OCD are regressed to developmentally
earlier stages of the infantile super ego, whose harsh,
punitive characteristics, which now reappear as part
of the psychopathology.
• Regression to the pre-oedipal, anal sadistic phase
combined with the use of specific ego defense
mechanisms (isolation, undoing, displacement,
reaction formation) produces the clinical symptoms
of obsessions and compulsions.
 BEHAVIOUR THEORY
• This theory explains obsessions as a conditioned
stimulus to anxiety.
• Compulsions have been described as learned
behaviour that decreases the anxiety associated with
obsessions.
• This decrease in anxiety positively reinforces the
compulsive acts and they become stable learned
behaviour.
 CLINICAL FEATURES
• Obsessional thoughts
Words, ideas and beliefs that intrude forcibly into
patient’s mind. They are usually unpleasant and
shocking to the patient and may be obscene or
blasphemous.
• Obsessional image
These are vividly imagined scenes, often of a violent or
disgusting kind involving abnormal sexual practices.
• Obsessional ruminations
These involve internal debates in which arguments for
and against even the simplest everyday actions are
reviewed endlessly.
• Obsessional impulses
These are urges to perform acts, usually of a violent or
embarrassing kind, such as injuring a child, shouting
in church.
• Obsessional rituals
These may include both mental activities counting
repeatedly in a special way or repeating a certain form
of words, and repeated but senseless behaviors.
Sometimes such compulsive acts may be preceded by
obsessional thoughts.
 Obsessive slowness
Severe obsessive ideas or extensive compulsive rituals
characterize obsessional slowness in the relative
absence of manifested anxiety. This leads to marked
slowness in daily activities.
 Other features are

• Recognition that the thoughts are produced in his or

her own mind.
• Lack of concentration and task completion.
• Impaired social or work functioning.
 COURSE AND PROGNOSIS

Long and fluctuating course

Prognosis appears to be worse when the onset is in
childhood, the personality is obsessional, symptoms
are severe, compulsions are bizarre, or there is a
coexisting major depressive disorder.
DIAGNOSIS

•History collection, Mental Status Examination,

Physical examination

• Imaging studies like MRI, CT, PET

• Based on ICD criteria

• Rating scales to assess severity of OCD. E.g. Y-

BOCS (Yale-Brown Obsessive Compulsive Scale),
Maudsley Obsessive Compulsive Inventory
 TREATMENT
Pharmacotherapy

 Benzodiazepines; limited role E.g. alprazolam,

clonazepam

 Antidepressants;

SSRIs- e.g. Fluoxetine 20-80mg/day, Fluvoxamine

50-200mg/day, Paroxetine 20-40mg/day, and
Sertraline 50-200mg/day
 Non-specific SRI- Clomipramine 75-300mg/day,
was the first drug used effectively in the treatment of
OCD.

 Antipsychotics; Occasionally used in low doses in

the treatment of severe, disabling anxiety. E.g.
haloperidol, risperidone, aripiprazole, pimozide

 Buspirone has also been used beneficially as an

adjunct for augmentation of SSRIs.
PSYCHOTHERAPY USED IN ANXIETY DISORDERS

 Psychoanalytic psychotherapy to those

patients who are psychologically oriented.

 Supportive psychotherapy to the clients as

well as the family members.
 BEHAVIOUR THERAPY
•Exposure and Response Prevention (ERP)
• Thought stoppage

• Relaxation technique

• Systematic desensitization

• Modeling

• Aversive conditioning techniques

EXPOSURE AND RESPONSE PREVENTION
(ERP):

 Repeated exposure to the source of

patient’s obsession.

 Then the patient is asked to refrain

from the compulsive behaviour that the
patient usually performed to reduce the
anxiety.
 For example, compulsive hand washers are
encouraged to touch contaminated objects and
then refrain from washing in order to break the
negative reinforcement chain.
 THOUGHT STOPPAGE
 It help an individual to learn to stop thinking
unwanted thoughts. Steps are,
 Ask client to sit comfortably and ask to
bring the unwanted thoughts into the
conscious mind at a rate of one at a time.
 As soon as the thought forms, give the
command ‘STOP’. Follow this with calm
and deliberate relaxation of muscles and
diversion of thought to something pleasant.
 Repeat the procedure to bring the unwanted
thought under control.
RELAXATION TECHNIQUE:

 Includes deep breathing exercise, Progressive

Muscle Relaxation, meditation, imagery, music etc.

 Modeling- The person is exposed to a model

behaviour and is induced to copy it.
AVERSIVE CONDITIONING TECHNIQUES-

 Pairing of pleasant stimulus with unpleasant

response,
 so that even in absence of unpleasant response,
the pleasant stimulus becomes unpleasant by
association.
SYSTEMATIC DESENSITIZATION-

 It is based on work of Joseph Wolpe.

 Desensitization (also known as exposure

therapy), is a cognitive-behavioural therapy in
which people are gradually exposed to the
frightening object or event until they
become used to it and their physical symptoms
decrease.
Components of
Desensitization
• Relaxation
• Hierarchy
construction
• Visualizations
• Item presentation
• In vivo assignments
 PROCEDURE
 Teach progressive relaxation.

 The client is asked to outline an anxiety or phobia

hierarchy, a step by step approximation of the feared
situation in which the client, with guidance from the
therapist, lists the lowest anxiety situation to the highest.
This is called hierarchy construction.

 During visualization training, a client imagines himself

in a variety of situations.
 In item presentations client relaxes and then imagines
himself in each of phobic situations on the hierarchy he
was created. It should be done in a slow and systematic
fashion: one item at a time.

 The client is advised to signal whenever anxiety is

produced. With each signal, he is asked to relax. After a few
trials, the client is able to control his anxiety.

 Thus gradually the hierarchy is climbed till the maximum

anxiety-provoking stimulus can be faced in absence of
anxiety.
 Electroconvulsive therapy
• Indicated in patients with severe depression,
suicidal risk etc.
 Psychosurgery

• The procedures used are Stereotactic limbic

leucotomy and Stereotactic subcaudate
tractotomy.
• It is available only at very few centers in the
world.
NURSING MANAGEMENT

Assessment
 Collection of physical, psychological and social data

 Know the impact of obsessions and compulsions on physical

functioning, mood, self-esteem and normal coping ability

 Identify defence mechanisms used, thought content,

potential for suicide, ability to function, and social support

system available.
 NURSING MANAGEMENT
Nursing diagnosis 1
 Severe Anxiety related to earlier life conflicts as evidenced by
repetitive action (e.g., hand-washing), recurring thoughts
(e.g., dirt and germs), decreased social and role functioning
Goals
 Demonstrates ability to cope effectively with
stressfulsituations without resorting to obsessive thoughts or
compulsive behaviors.
Interventions
 Establish relationship through use of empathy, warmth, and
respect.
 Verbalize empathy toward client’s experience rather than
disapproval or criticism.
• Assist client to learn stress management, (e.g., thought
stopping, relaxation exercises, imagery).
• Identify what the client perceives as relaxing (e.g. warm
bath, music).
• Engage in constructive activities such as quiet games that
require concentration.
• Encourage participation in a regular exercise program.
• Give positive reinforcement for non-compulsive behavior.
Avoid reinforcing compulsive behavior.
• Assist client to find ways to set limits on own behaviors. At
the same time allow adequate time during the daily routine
for the ritual(s).
• Limit the amount of time allotted for the performance of
rituals. Encourage client to gradually decrease this time.
• Discuss home situation, include family in discharge plan.
NURSING DIAGNOSIS 2

• Ineffective individual coping related to

underdeveloped ego, punitive superego, avoidance
learning, possible biochemical changes, evidenced by
ritualistic behavior or obsessive thoughts.
Goal
 • Demonstrates ability to cope effectively without
resorting to obsessive-compulsive behaviors.
 Interventions

• Work with patient to identify the situations that

increase anxiety and result in compulsive acts.
• Encourage independence in patient and give positive
reinforcement for independent behaviours.
• In the beginning of treatment, give plenty of time for
ritualistic behavior. Do not be judgmental or verbalize
disapproval of behavior.
• Support patient’s efforts to explore the meaning and
purpose of behavior.
• Provide structured schedule of activities for the
patient, including adequate time for completion of
rituals.
• Gradually limit the amount of time allotted for
ritualistic behavior as patient becomes more involved
in unit activities.
• Give positive reinforcement for non-ritualistic
behaviors.
• Help patient to learn techniques like thought
stopping, relaxation and exercise.
NURSING DIAGNOSIS 3

• Impaired social interaction related to inability to

control thoughts, images and impulses in a
purposeful, voluntary manner.
Goal
 • Verbalizes understanding that thoughts, impulses
and images are involuntary and may worsen with
stress.
Interventions
• Approach client in a calm, direct, non-authoritarian
manner, using a soft tone of voice.
• Listen actively to the client’s obsessive themes no
matter how absurd or incongruent they may seem.
• Assist client to gain control of overwhelming feelings
and impulses through verbal interactions.
• Protect the client who is at the risk for suicide.
• Assist client in planning the rest periods between
planned activities and rituals.
• In the beginning of treatment, give plenty of time
for ritualistic behavior. Do not be judgmental or
verbalize disapproval of behavior.
• Gradually limit the amount of time allotted for
ritualistic behavior as patient becomes more
involved in unit activities.
• Activate the client toward activities that will
reduce stress or anxiety (warm bath, taking
walk, listening to music etc.)
• Ask client to stay connected to family and friends.
 • Ask client to choose one or two ‘worry periods’
each day, time he can devote to obsessing. The
rest of the day, however, is to be designated free
of obsessions and compulsions.
 When thoughts or urges come into patient during
the day, write them down and ‘postpone’ them to
worry period.
NURSING DIAGNOSIS 4

 • Ineffective role performance related to the need

to perform rituals, evidenced by inability to fulfil
usual patterns of responsibility.
Goal
• Client resumes role-related responsibilities.
Interventions
 Determine patient’s previous role within the
family and the extent to which this role is
impaired by the illness.
 Encourage patient to discuss conflicts evident
within the family system. Identify the responses
of patient and family members.
 Explore available options for changes in role.
Practice through role-play.
 Give patient lots of positive reinforcement for
ability to resume role responsibilities by
decreasing need for ritualistic behaviors.
 EPIDEMIOLOGY

30 28.7
The Lifetime Prevalence (%)

25
20
15 13.3
11.3
10 7.6
5.3 5.1
5 3.5

0
All Anxiety Disorders
Social Phobias
Specific Phobias PTSD
Agorafobia without Panic
GAD Panic Disorders

Kessler et al., 1995

DISSOCIATIVE (CONVERSION)
DISORDERS
 DISSOCIATIVE (CONVERSION) DISORDERS
 Dissociative disorders are defined by a disturbance of or
alteration in the usually integrated functions of
consciousness, memory, and identity (Black &
Andreasen, 2011).

 During periods of intolerable stress, the individual

blocks off part of his or her life from consciousness.

 The stressful emotion becomes a separate entity, as

the individual “splits” from it and mentally drifts
into a fantasy state.
F44 DISSOCIATIVE (CONVERSION) DISORDERS
F44 Dissociative (conversion) disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorders
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.7 Mixed dissociative (conversion) disorders
F44.8 Other dissociative (conversion) disorders
F44.9 Dissociative (conversion) disorder, unspecified
 EPIDEMIOLOGY

 Constitutes about 6-15% of all outpatient

diagnoses and 14-20% of all neurotic disorders.

 Females usually out number males, but in

children the percentage tends to be similar in
boys and girls.
CHARECTORSTICS
1. Presence of symptoms or deficits
affecting motor or sensory function,
suggesting a medical or neurological
disorder.
2. Sudden onset.
3. Development of symptoms usually in the
presence of a significant psychosocial
stressor(s).
4. A clear temporal relationship between
stressor and development or exacerbation of
symptoms.
5. Patient does not intentionally
produce the symptoms.
6. There is usually a ‘ secondary gain’.
SECONDARY GAIN
7. Detailed physical examination and
investigations do not reveal any abnormality
that can explain the symptoms adequately.

8. The symptom may have a ‘symbolic’

relationship with the stressor/conflict.

9. la-belle-indifférence, which is a lack of concern

towards the symptoms,
DISSOCIATIVE AMNESIA
 The main feature is loss of memory, usually of
important recent event,
 which is not due to organic mental disorder and not
a ordinary forgetfulness or fatigue.
 The amnesia is usually centered on traumatic events,
such as accidents, combat experiences, or unexpected
bereavements, and used to be partial and selective.
 The amnesia typically develops suddenly and can last
from minutes to days.
 Differential diagnosis: complicated; it is necessary to
rule out all organic brain disorders as well as
various intoxications. The most difficult differentiation is
from conscious simulation - malingering.
TYPES
a. Localized Amnesia: Inability to recall all
incidents associated with a traumatic event.
It may be broader than just a single event,
however, such as being unable to remember months
or years of child abuse (APA, 2013).
b. Selective Amnesia: Inability to recall only
certain incidents associated with a traumatic
event for a specific period following the event.
c. Generalized Amnesia: Inability to recall all
events encompassing one’s entire life,
including one’s identity.
CASE SCENARIO
 A 45-year-old, divorced, left-handed, male bus
dispatcher was seen in psychiatric consultation
on a medical unit.
 He had been admitted with an episode of chest
discomfort, light headedness, and left-arm
weakness.
 He had a history of hypertension and had a
medical admission in the past year for ischemic
chest pain, although he had not suffered a
myocardial infarction.
 Psychiatric consultation was called, because the
patient complained of memory loss for the
previous 12 years, behaving and responding to
the environment as if it were 12 years previously
(e.g., he didn't recognize his 8-year-old son,
insisted that he was unmarried, and denied
recollection of current events, such as the current
president).
 Physical and laboratory findings were unchanged
from the baseline.
 Brain computed tomography (CT) scan was
normal.
 The patient described a family history of brutal
beatings and physical discipline.
 He was a decorated combat veteran, although he
described amnestic episodes for some of his
combat experiences.
DISSOCIATIVE FUGUE
 Dissociative fugue is characterized by a sudden,
unexpected travel away from customary
place of daily activities or by bewildered
wandering, with the inability to recall some or all
of one’s past.
 An individual in a fugue state may not be able to
recall personal identity and sometimes assumes
new identity (Black & Andreasen, 2011).
 DISSOCIATIVE STUPOR
 The individual suffers from diminution or absence of
voluntary movement and normal responsiveness to
external stimuli such as light, noise, and touch.
 The person lies or sits largely motionless for long
periods of time.
 Speech and spontaneous and purposeful movement are
completely absent.
 Muscle tone, posture, breathing, and sometimes eye-
opening and coordinated eye movements are such that it
is clear that the individual is neither asleep nor
unconscious.
 Positive evidence of psychogenic causation in the form of
either recent stressful events or prominent interpersonal
or social problems.
TRANCE AND POSSESSION DISORDERS

 There is a temporary loss of both the sense of

personal identity and full awareness of the
surroundings.
 The individual can act as if taken over by another
personality, spirit, deity, or “force”.
 Repeated sets of extraordinary movements,
postures, and utterances can be observed.
 DISSOCIATIVE DISORDERS OF MOVEMENT AND
SENSATION ( IN ICD-10)
 There is a loss of or interference with
movements or loss of sensations (usually
cutaneous). Mild and transient varieties of these
disorders are often seen in adolescence,
particularly in girls, but the chronic varieties are
usually found in young adults.
 Dissociative motor disorders-paralysis or abnormal
movements
 Dissociative convulsions
 Dissociative anaesthesia

 Ganser’s syndrome – “approximate” or grossly

incorrect answers
MULTIPLE PERSONALITY DISORDER OR
DISSOCIATIVE IDENTITY DISORDER (DID)
 Multiple personality disorder means the
apparent existence of two or more distinct
personalities within an individual, with only
one of them being evident at a time (Mr. Jekyl
and Mr. Hyde).
 Each personality is complete, with its own
memories, behaviors, and preferences, but
neither has access to the memories of the other
and the two are almost always unaware of each
other’s existence.
 Change from one personality to another is in the
first instance usually sudden and closely
associated with traumatic events.
DISSOCIATIVE IDENTITY DISORDER (DID)
AETIOLOGY
Predominantly of three types:
 Psychodynamic Theory

 Behavioural Theory

 Biological Theory
PSYCHODYNAMIC THEORY
BEHAVIOURAL THEORY
 Learned responses in the face of stress
 For the first time, the symptom may be learned
from the surrounding environment (e.g. seeing
a paralysed patient).
 Brings psychological relief by avoidance of
stress and is thus secondarily reinforced.
BIOLOGICAL THEORY
 80% of patients, diagnosed as ‘hysteria’, were
later found to have physical illnesses.
 Cerebral cortex lesions
CLINICAL MANAGEMENT

Behaviour Therapy:
 symptoms should not be focussed on.

 Treated normal- not encouraged to stay in a sick-

role.
 When there is a sudden, acute symptom, its
prompt removal may prevent habituation and
future disability.
1. Strong suggestion for a return to normalcy.
2. Aversion therapy- (liquor ammonia; aversive
electric stimulus; pressure just above eye balls or
tragus of ear; closing the nose and mouth)
Psychotherapy with Abreaction.
 Abreaction is bringing to the conscious awareness
of thoughts, affects and memories for the first
time.
 This may be achieved by:

i. Hypnosis.
ii. Free association.
iii. Intravenous thiopentone or diazepam (make the
patient more suggestible to therapist’s advice).
 Supportive Psychotherapy: when the conflicts
(and the current problems) have become
conscious and have to be faced in routine life.
NURSING DIAGNOSIS
1. Ineffective coping Rlt [Severe level of
anxiety, repressed] [Childhood trauma]
[Childhood abuse] [Low self-esteem],
[Regression], [Inadequate coping skills]
2. Impaired memory Rlt [Severe level of anxiety,
repressed] [Childhood trauma] [Childhood
abuse] [Threat to physical integrity] [Threat to
self-concept]
3. Disturbed personal identity
F45 SOMATOFORM DISORDERS

F45 Somatoform disorders

F45.0 Somatization disorder
F45.1 Undifferentiated somatoform
disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified
F45 SOMATOFORM DISORDERS
 The somatoform disorders are characterised by
repeated presentation with physical symptoms which
do not have any adequate physical basis (and are not
explained by the presence of other psychiatric
disorders), and a persistent request for investigations
and treatment despite repeated assurances by the
treating doctors.
 Characteristics of somatoform disorders:
1. somatic complains of many medical maladies without
association with serious demonstrable peripheral organ
disorder
2. psychological problems and conflicts that are important
in initiating, exacerbating and maintaining the
disturbance
F45.0 SOMATIZATION DISORDER
DIAGNOSTIC GUIDELINES
A definite diagnosis requires the presence of all of
the following:
a) at least 2 years of multiple and variable
physical symptoms for which no adequate
physical explanation has been found,
b) persistent refusal to accept the advice or
reassurance of several doctors that there is no
physical explanation for the symptoms,
c) some degree of impairment of social and family
functioning attributable to the nature of
symptoms and resulting behavior.
 D) There is frequent change of treating
physicians.
COMMON SYMPTOMS
 Gastrointestinal (abdominal pain, belching,
nausea, vomiting, regurgitation),
 abnormal skin sensations (numbness,
soreness, itching, tingling, burning), and
 sexual and menstrual complaints
(menorrhagia, dysmenorrhoea, dyspareunia).
EPIDEMIOLOGY
 general population is estimated to be 0.2 percent
to 2 percent.
 With a 5-to-1 female-to-male ratio.

 commonly coexists with other mental disorders-

OCD, Avoidant, paranoid, self-defeating,
Personality Disorder
ETIOLOGY
 Psychosocial Factors
 Biological Factors
PSYCHOSOCIAL FACTORS

 Interpretations of the symptoms as social

communication whose result is to avoid
obligations(e.g., going to a job a person does not
like), to express emotions (e.g., anger at a
spouse), or to symbolize a feeling or a belief (e.g.,
a pain in the gut).
 symptoms substitute for repressed instinctual
impulses.
 People with somatization disorder come from
unstable homes and have been physically abused
BIOLOGICAL FACTORS

 have characteristic attention and cognitive

impairments that result in the faulty perception
and assessment of somatosensory inputs.
 Genetics- Somatization disorder tends to run in
families and occurs in 10 to 20 percent of the
first-degree female relatives
 29 percent in monozygotic twins and 10 percent
in dizygotic twins
CASE SCENARIO
 F45.0 SOMATIZATION DISORDER
THERAPY AND PROGNOSIS
 Chronic relapsing condition starting in
adolescence or even as late as the third decade of
life.

 New symptoms during the emotional distress.

 Typical episodes last 6 to 9 months; quiescent

time of 9 to 12 months.
MANAGEMENT STRATEGIES
 Supportive Psychotherapy: establishing a
rapport. It is useful to demonstrate the link
between psychosocial conflict(s) and somatic
symp toms, if it is apparent.
 Behaviour modification: not focusing on the
symp toms and positively reinforcing normal
functioning.
 Relaxation therapy, with graded physical
exercises
 Drug therapy: Antidepressants and/or
benzodiazepines can be given on a short-term
basis for associated depression and/or anxiety.
 F45.2 HYPOCHONDRIACAL DISORDER
 The disorder is characterized by a persistent
preoccupation and a fear of developing or having one or
more serious and progressive physical disorders.
 Patients persistently complain of physical problems or are
persistently preoccupied with their physical appearance.
 The fear is based on the misinterpretation of physical
signs and sensations.
 Physician physical examination does not reveal any
physical disorder, but the fear and convictions persist
despite the reassurance.
 F45.2 HYPOCHONDRIACAL DISORDER
DIAGNOSTIC GUIDELINES
 Presence of both of the following criteria:
1. persistentbelief in the presence of at least one
serious physical illness underlying the presenting
symptom or symptoms, even thought repeated
investigations and examinations have not identified
any adequate physical explanation, or a persistent
preoccupation with presumed deformity or
disfigurement
2. persistent refusal to accept the advice and
reassurance of several different doctors that there is
no physical illness or abnormity underlying the
symptoms
 Includes: Body dysmorphic disorder, Dysmorphophobia
(non delusional), Hypochondriacal neurosis,
Hypochondriasis, Nosophobia
F45.2 HYPOCHONDRIACAL DISORDER
THERAPY AND PROGNOSIS
 The illness is usually long-standing, with episodes
lasting months or years. Recurrences occur frequently
after psychosocial distress.
 Higher socio-economic status, presence of other treatable
condition, anxiety and depression, an acute onset,
absence of personality disorder or comorbid organic
disease predict better outcome.
 No evidence-based treatment has been described.
 Patients strongly refuse the mental health care
professionals and remain in primary health care.
 Similar management and group therapy strategy as in
somatization disorder may be useful.
 F45.3 SOMATOFORM AUTONOMIC
DYSFUNCTION
 The symptoms are presented as physical disorder of
system or organ largely or completely under controlled by
autonomic innervation, i.e. the cardiovascular,
gastrointestinal, or respiratory system and some aspects
of genitourinary system.
 The symptoms are usually of two types:
1. complaints based on objective signs of autonomic arousal
(palpitation, sweating, flushing, tremor)
2. idiosyncratic, subjective, non-specific (fleeting aches and pains,
burning, heaviness, tightness, sensation of being bloated or
distended)
 These symptoms patients refer to a specific organ or
system.
 In many cases there is evidence of psychological stress or
current problems related to the disorder.
F43 REACTION TO SEVERE STRESS, AND
ADJUSTMENT DISORDERS

F43 Reaction to severe stress, and

adjustment disorders
F43.0 Acute stress reaction
F43.1 Post-traumatic stress disorder
F43.2 Adjustment disorders
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified
 POST-TRAUMATIC STRESS DISORDER (PTSD)
 PTSD is a delayed and/or protracted response to
a stressful event of an exceptionally threatening
or catastrophic nature.
 The three major elements of PTSD include
1) reexperiencing the trauma through dreams or
recurrent and intrusive thoughts (“flashbacks”)
2) showing emotional numbing such as feeling detached
from others
3) having symptoms of autonomic hyperarousal such as
irritability and exaggerated startle response,
insomnia
DSM-IV-TR DIAGNOSTIC CRITERIA
A. The person has been exposed to a traumatic
event in which both of the following were present:
1. the person experienced, witnessed, or was
confronted with an event or events that involved
actual or threatened death or serious injury, or a
threat to the physical integrity of self or others

2. the person's response involved intense fear,

helplessness, or horror.
 DSM-IV-TR DIAGNOSTIC CRITERIA………………….

B. The traumatic event is persistently reexperienced in

one (or more) of the following ways:
1. recurrent and intrusive distressing recollections of the
event, including images, thoughts, or perceptions.
2. recurrent distressing dreams of the event.
3. acting or feeling as if the traumatic event were
recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback
episodes, including those that occur on awakening or
when intoxicated).
DSM-IV-TR DIAGNOSTIC CRITERIA………………….

4. intense psychological distress at exposure to

internal or external cues that symbolize or
resemble an aspect of the traumatic event
5. physiological reactivity on exposure to internal
or external cues that symbolize or resemble an
aspect of the traumatic event
DSM-IV-TR DIAGNOSTIC CRITERIA………………….

C. Persistent avoidance of stimuli associated with

the trauma and numbing
1. efforts to avoid thoughts, feelings, or conversations
associated with the trauma
2. efforts to avoid activities, places, or people that arouse
recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest or participation in significant
activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving
feelings)
7. sense of a foreshortened future (e.g., does not expect to
have a career, marriage, children, or a normal life span)
DSM-IV-TR DIAGNOSTIC CRITERIA………………….

1. difficulty falling or staying asleep

2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
 E. Duration of the disturbance is more than 1
month
POST-TRAUMATIC STRESS DISORDER (PTSD)

Acute Flashback
Reaction
on Trauma

Trauma
CLINICAL MANAGEMENT

 Pharmacological approach:
 Antidepressant(SSRI)- Citalopram 20 mg to 40
mg- children
 In adult – clonidine(0.05 to 0.1 mg twice daily) and
propranolol
 short-term benzodiazepines trials
 mood stabilizers (carbamazepine, valproate)
 antipsychotics
PSYCHOTHEREAPY
Trauma-Focused Cognitive-Behavior Therapy
 Psychoeducation- regarding `emotional and
physiological reactions to traumatic events.
 Stress inoculation- guided to utilize muscle
relaxation, focused breathing, affective
modulation, thought-stopping, and cognitive
coping techniques to diminish feelings of
helplessness and distress.
 Gradual exposure-technique for a child to
recall traumatic events.
 Cognitive processing- identifying those
associated thoughts, feelings, and ideas that
may be inaccurate
REACTION TO SEVERE STRESS, AND
ADJUSTMENT DISORDERS
 This category differs from others in that it includes
disorders identifiable not only on grounds of
symptomatology and course but also on the basis of one or
other of two
 Causative influences:
 an exceptionally stressful life event (e.g. natural or man-made
disaster, combat, serious accident, witnessing the violent death of
others, or being the victim of torture, terrorism, rape, or other
crime) producing an acute stress reaction
 significant life change leading to continued unpleasant
circumstances that result in an adjustment disorder
 Stressful event is thought to be the primary and
overriding causal factor, and the disorder would not have
occurred without its impact.
 ACUTE STRESS REACTION
 A transient disorder of significant severity, which develops in an
individual without any previous mental disorder in response to
exceptional physical and/or psychological stress.
 Not all people exposed to the same stressful event develop the
disorder.
 The symptoms: an initial state of „daze”, with some constriction of the
field of consciousness and narrowing of attention, inability to
comprehend stimuli, and disorientation. This state may be followed
either by further withdrawal from the surrounding situation (extreme
variant - dissociative stupor), or by agitation and overactivity.
 Autonomic signs - tachycardia, sweating or flushing, as well as other
anxiety or depressive symptoms.
 The symptoms usually appear within minutes of the impact of the
stressful event, and disappear within several hours, maximally 2—3
days.
 ADJUSTMENT DISORDERS
 Adjustment disorder comprises states of subjective distress and
emotional disturbance arising in the period of adaptation to a
significant life change or to the consequences of a stressful life event,
such as serious physical illness, bereavement or separation,
migration or refugee status.
 The clinical picture: depressed mood, anxiety, worry, a feeling of
inability to cope, plan ahead, or continue in the present situation,
and some degress of disability in the performance of daily routine.
 Onset - within 1 month; duration - below 6 months.
 More frequently women, unmarried and young persons.

 Psychotherapy is the first line treatment of this disorder.

Symptomatic treatment may comprise short trial of hypnotics or
benzodiazepines.
F45.3 SOMATOFORM AUTONOMIC DYSFUNCTION
DIAGNOSTIC GUIDELINES
a) Symptoms of autonomic arousal such as
palpitations, sweating, tremor, flushing which
are troublesome and persistent
b) Additional subjective symptoms referred to
specific organ or system
c) Preoccupation with the symptoms and
possibility of serious (often non specified
disorder). It does not respond to repeated
explanations and reassurance of physicians
d) No evidence of a significant disturbance of
structure or function of the system or organ
F45.3 SOMATOFORM AUTONOMIC DYSFUNCTION
DIFFERENTIAL DIAGNOSIS
 In comparison with generalized anxiety there is
predominance of psychological component of autonomic
arousal. In somatization disorders autonomic
symptoms when they are present they are nor
prominent nor persistent and symptoms are not so
persistently attributed to one organ or system.
 Excludes: psychological and behavioural factors
associated with disorders or diseases classified
elsewhere (F54).
 The individual disorder may be classified by fifth
character indicating the organ or system affected
F45.3 SOMATOFORM AUTONOMIC DYSFUNCTION
THERAPY AND PROGNOSIS
 Similar chronic relapsing condition as the
somatization disorder.
 Patients report worse health than do those with
chronic medical condition and their report of specific
symptoms if they meet the severity criteria is
sufficient and need not to be considered legitimate by
the clinician.
 Treatment strategies will be similar stressing the
importance of the interdisciplinary collaboration.
F45.4 PERSISTENT SOMATOFORM PAIN
DISORDER

 The predominant symptom is a persistent severe

and distressing pain that cannot be explained
fully by a physiological process of physical illness.
 Pain occurs in association with emotional
conflicts or psychosocial problems.
 The expression of chronic pain may vary with
different personalities and cultures.
 The patient is not malingering and the
complaints about the intensity of the pain are to
be believed.
F45.4 PERSISTENT SOMATOFORM PAIN
DIAGNOSTIC GUIDELINES

 The clinical examination should focus on

a) the extend the patient is disabled by the pain
b) the degree of complicating emotional factors and comorbid
psychiatric conditions

 Includes: psychalgia, psychogenic backache or

headache, somatoform pain disorder.
F45.4 PERSISTENT SOMATOFORM PAIN
DIFFERENTIAL DIAGNOSIS
 Not included:
 pain presumed to be of psychological origin occurring during
the course of depression or schizophrenia
 pain due to known or inferred physiological mechanism such
as muscle tension pain or migraine but still believed to have
psychological cause are coded as P54
 the somatoform pain disorder has to be differentiated from
histrionic behaviour in reaction to organic pain
 Excluded backache NOS (M54.9), pain NOS (acute,
chronic) (R52.-), tension type headache (G44.2).
F45.4 PERSISTENT SOMATOFORM PAIN
THERAPY AND PROGNOSIS

 Once diagnosis is completed the outpatient

treatment on regular basis by one interested
physician has to be carried out.
 Patients have to be reassured that the treatment
continues if there is some improvement.
 Those with pain-prone reaction to distress are
described to have poor or transient improvement.
 Patients with comorbid depression may improve
with antidepressant medication.
 Treatment with any type of the pain disorder
subtypes needs to be multidisciplinary and
multidimensional from the onset.
F45.8 OTHER SOMATOFORM DISORDERS
 In these disorders the presented complaints are not mediated through
the autonomic nervous, and are limited to specific system of body
part.
 Any other disorders of sensation not due to physical disorders which
are closely associated in time with stressful event or problem and
which results in significant increase of attention for the patient,
personal or medical care should also be classified here.
 Swelling, movement on the skin and paraesthesias (tingling or/and
numbness) are common.
 Disorders included in this category:
a) “globus hystericus
b) psychogenic torticollis and other disorders of spasmodic movement
(excluding Tourette’s syndrome)
c) psychogenic pruritus but excluding specific skin lesions such as alopecia,
dermatitis eczema, or urticaria of psychogenic origin
F45.9 SOMATOFORM DISORDER, UNSPECIFIED

 Includes unspecified physiological or

psychosomatic disorder in patients whose
symptoms and associated disability do not
fit the full criteria for other somatoform
disorders. The treatment and the outcome
however do not considerably differ.
OTHER NEUROTIC DISORDERS

F48 Other neurotic disorders

F48.0 Neurasthenia
F48.1 Depersonalization-derealization
syndrome
F48.8 Other specified neurotic disorders
F48.9 Neurotic disorder, unspecified