Unit 8 neurotic stress and somatoform, PSYCHIATRIC NURSING

NURSING MANAGEMENT
OF PATIENT WITH
NEUROTIC, STRESS-
RELATED AND
SOMATOFORM DISORDERS
Prepared by:
Mr. Vipin Chandran
1

The term “Neurosis” is derived from two greek
words, ‘Neuron’ means ‘nerve’ with the suffix ‘osis’
means ‘diseased’ or ‘abnormal condition’.
Majority of people are affected by neurosis in some
mild form or other, which may include physical
symptoms e.g anxiety, hysteria, phobia,
depression, obsessive compulsive tendencies.
NEUROSIS 2

CLASSIFICATION:
Neurosis
Anxiety Disorder Phobia OCD Dissociative
Disorder
Somatoform
Disorder
Hypochon
-
driasis
PTSD
3

F40-F48 NEUROTIC, STRESS-RELATED &
SOMATOFORM DISORDERS
F40 - Phobic anxiety disorders
F41 - Other anxiety disorders
F42 - Obsessive compulsive disorders
F43 - Reaction to severe stress & adjustment
disorders
F44 - Dissociative (Conversion) disorders
F45 - Somatoform disorders
F48 - Other neurotic disorders
ICD-10 CLASSIFICATION: 4

Anxiety is a ‘normal’ phenomenon which is
characterized by a state of apprehension or unease
arising out of anticipation of danger.
1.ANXIETY DISORDER: 5

Types of anxiety:
1): Trait theory: this is habitual tendency to be
anxious in general (a trait). “I often feel anxious”
2): State anxiety: this is the anxiety felt at the
present. “I feel anxious now”
6

I. PHYSICAL SYMPTOMS
a): Tremors
b): Restlessness
c): Muscle twitches
d): Fearful Facial Expression
e): Palpitation
f): Tachycardia
g): Sweating
h): Dyspnea
i): Diarrhoea
CLINICAL SYMPTOMS: 7

II. PSYCHOLOGICAL SYMPTOMS
a): Poor Concentration
b): Distractibility
c): Hyper arousal
d): Negative automatic thoughts
e): Derealization
f): Depersonalization
g): Fearfulness
h): Inability to relax
i): Insomnia

It is characterized by an Insidious onset in third decade,
usually chronic course which may or may not be with
panic attacks (episodes of acute anxiety).
Symptoms should last for at least 6 months to diagnose
G.A.D.
GENERALIZED ANXIETY DISORDER
9

It is characterized by discrete episodes of acute anxiety
onset is in early third decade, with chronic course.
Panic attack occur recurrently every few days last for few
minutes & characterized by very severe anxiety.
PANIC DISORDER 10

1. Psychodynamic Theory:
Anxiety is a signal that disturb internal
psychological equilibrium. This is called signal
anxiety.
It arouses ego to take defensive action
(Repression) primary. When it fails (Conversion,
Isolation) secondary.
ETIOLOGY: 11

2. Behavioral Theory:
According to this theory, Anxiety is an
unconditioned inherent response of organism to
painful or dangerous stimuli.
3. Cognitive Behavioral Theory:
There is evidence of selective information
processing (more attention paid to threat- related
information), cognitive distortions, Negative
automatic thoughts.
ETIOLOGY: 12

4. Biological Theory:
a). Genetic evidence: 15-20% Ist degree relative
Monozygotic- 80%
Dizygotic- 20%
b). Chemically Induced:
GABA it is the most prevalent inhibitory
neurotransmitter in the CNS. Alteration in GABA
levels lead to production of Anxiety.
ETIOLOGY: 13

Treatment of anxiety disorder is usually multimodal
1. Psychotherapy (Supportive & CBT etc)
2. Relaxation techniques (Exercise, Yoga, Pranayama,
Meditation)
3. Other behavior therapies (Biofeedback &
Hyperventilation control)
4. Drug treatment:
- Benzodiazepines (GAD)
- Antidepressant (Panic Disorder)
- Beta Blockers (Propranolol & atenolol)
- Buspirone (Anti-anxiety Drug)
TREATMENT: 14

Phobia is defined as irrational fear of a specific
object, situation or activity, often leading to
persistent avoidance of the feared object, situation
or activity.
2. PHOBIC DISORDER: 15

a): Presence of fear of an object, situation or
activity.
b): Patient recognizes the fear as irrational &
unjustified
c): Patient is unable to control fear
d): It leads to persistent avoidance of a particular
object, situation or activity.
CHARACTERISTIC FEATURES: 16

It is characterized by an irrational fear of situations or
being in places away from the familiar setting of home. It
includes fear of open spaces, public spaces, crowded
places, where there is no escape.
AGORAPHOBIA: 17

Irrational fear of activities or social interaction,
characterized by irrational fear of performing
activities in the presence of other people or
interacting with others.
SOCIAL PHOBIA: 18

It is characterized by an irrational fear of a
specified object or situation. Some of the example
of simple phobia include-
*Acrophobia
*Zoophobia
*Xenophobia
*Algophobia
*Claustrophobia
SPECIFIC PHOBIA: 19

1. Psychodynamic Theory:
Anxiety is usually dealt with defense mechanism of
(Repression) when it fails, secondary defense
mechanism (Displacement) come into action.
2. Behavioral Theory:
It explains phobia as a conditioned reflex.
3. Biological Theory:
All phobias especially agoraphobia are closely
linked to panic disorders..
ETIOLOGY: 20

Treatment approach is usually multimodal:
1. Psychotherapy (Supportive, Behavior therapy, CBT
etc).
2. Drug treatment:
- Benzodiazepines (Alprazolam)
- Antidepressant (SSRI, TCA, MAOI for panic attacks)
- Clonazepam, Diazepam
TREATMENT: 21

An obsession is defined as:
1): An Idea, impulse or image which intrudes into the conscious
awareness repeatedly.
2): It is recognized as irrational & absurd. (Insight is present)
3): Patient tries to resist against it but is unable to.
3. OBSESSIVE COMPULSIVE DISORDER:
22

Compulsion is defined as :
1): A form of behavior which usually follows
obsessions.
2): The behavior is not realistic and is either
irrational or excessive.
23

In India, OCD is more common in married males,
while In other countries, no gender differences are
reported. Average onset is late third decade in
India.
EPIDEMIOLOGY: 24

*ICD-10 Classifies OCD into three clinical
subtypes:
1): Predominately Obsessive thoughts or ruminations.
2): Predominately Compulsive acts (Compulsive rituals).
3): Mixed Obsessional thoughts & acts.
* Depression is very common associated with OCD

Four clinical syndrome have been described :
1|. Washers:
26

2|. Checkers:
27

3|. Pure Obsessions:
28

4|. Primary Obsessive Slowness:
Relatively rare syndrome, characterized by
severe obsessive ideas & extensive compulsive
rituals.
29

1].PSYCHODYNAMIC
THEORY
30
ETIOLOGY:

2]. BIOLOGICAL
THEORIES
32
ETIOLOGY:

1. Neurotransmitters:
Serotonin and Noradrenalin were found to have
higher level in brain.
2. Genetics:
It is transmitted genetically.
3. Electrophysiological Studies:
-Electroencephalography: Temporal lobes spikes
and increased theta waves
ETIOLOGY: 33

4. Brain Imaging:
Cranial CT and MRI Scans:
Increased ventricular- brain ratio, caudate nuclei.
ETIOLOGY: 34

3]. BEHAVIORAL THEORIES 35
From the learning theory perspective,
obsessions and compulsion are
understood as the result of interplay
of classical and operant conditioning
paradigms.

1]. PHARMACOLOGICAL
MANAGEMENT
36
TREATMENT MODALITIES:

PHARMACOLOGICAL MANAGEMENT 37
1): Clomipramine (25 to 75 mg in divided doses)
2): Fluoxetine (Antidepressant)
3): Fluvoxamine (Significant in Obsessive-
Compulsive Symptoms)

2]. BEHAVIOR THERAPY: 38
Classical Behavioral Therapy techniques have been
used in treatment of OCD. These include:
1) Systematic desensitization
2) Flooding
3) Modeling
4) Response prevention
5) Negative practice
6) Implosion
7) Thought stopping

2]. BEHAVIOR THERAPY: 39
8) Aversion relief
9) Shaping
10) Exposure and Response Prevention

3): Cognitive Behavior Therapy (Modeling
& Polarized thinking)
4): Psychotherapy (Supportive Insight-
oriented psychotherapies)
5): Electroconvulsive therapy (8-10 ECT)
6): Psychosurgery (Prefrontal leucotomy,
Transorbital Leucotomy, Rostral
Leucotomy, Tractomy)
40

Somatoform disorders is defined as the use of
physical symptoms to express emotional problems
and psychosocial stress. it is also known as
Hysteria or Briquet Syndrome.
4. SOMATOFORM DISORDERS:
41

Its main feature is pattern of multiple, recurring
and significant physical complaints
Classification of Somatoform Disorders:
1) Somatization Disorder
2) Undifferentiated Somatoform
3) Hypochondriacal Disorders
4) Somatoform Autonomic Dysfunction
5) Persistent Somatoform Pain Disorder
6) Other Somatoform Disorder
7) Somatoform Disorder Unspecified
42

It is characterized by presence of recurrent and
multiple frequently changing somatic complaints
of several years duration for which medical
attention has been sought, but these apparently
are not due to any physical disorder.
1.SOMATIZATION DISORDER:
43

Exact Etiology is not known but probably due to:
1. Familial Factors:
It has been found that risk to develop disorder is
10-20% in female first- degree relatives.
2. Socio- Cultural Factors:
It has been documented that the tendency to
perceive and report distress in psychological or
somatic term is influenced by various social &
cultural factors including stigma.
ETIOLOGY: 44

Symptoms may refer to any part of the body:
- Gastrointestinal symptoms
(Abdominal pain, Bowel problems,
Nausea, Vomiting, Regurgitation etc)
- Pain in various body part
(extremities, back, joint etc)
- Conversion symptoms
(Pseudoseizures, Fainting,
Incoordination, loss of voice,
difficulty in swalloing)

MANAGEMENT
46
TREATMENT MODALITIES:

Morrison has summarized the management of
somatization disorder in ABC as follows:
A. Accommodate initially
B. Behavior modification
C. Confrontation later about effects of behavior
D. Decrease drugs gradually
E. Educate about course and meaning of illness
F. Family involvement to give information
G. Guilt should be assuaged in physicians
H. Hospitalize
I. Intercurrent depression should be treated
conservatively.
47

2. Undifferentiated Somatoform Disorder:
When physical complaint are multiple, varying and
persistent but the complete and typical clinical
picture of somatisation disorder is not fulfilled, this
category is to be considered.
3. Hypochondriacal Disorder:
Essential features is a persistent preoccupation
with the possibility of having one or more serious
& progressive physical disorders.
48

4. Somatoform Autonomic Dysfunction:
Patient present the symptoms as if they were due
to a physical disorder of a system or organ that is
largely or completely under Autonomic innervation
& control like. (Cardio-vascular, GI, Respiratory
systems, Genito Urinary etc)
5. Persistent Somatoform Pain Disorder:
Predominant complaint is of persistent, severe,
distressing pain which cannot be explained fully
by a physiological process or a physical disorder.
49

6. Other Somatoform Disorder:
In these disorders the presenting complaints are
not mediated through the autonomic nervous
system and are limited to specific systems or parts
of the body.
50

It is characterized by a preoccupation with fear of having
or developing a serious physical illness. The fear is often
a result of unrealistic interpretation of physical signs or
sensations as evidence of disease.
5. HYPOCHONDRAISIS:
51

There are three theories of origin of hypochondriasis:
1. Psychodynamic theory:
Aggressive and Hostile wishes towards others are
transformed into physical complaints through
repression or displacement .
2. Socio- Cultural theory:
Sick role serves to convey about their distress and
disability to others, serving nonverbal
communication.
ETIOLOGY: 52

3. Neuropsychological theory:
hypochondriasis is the result of an underlying
perceptual or cognitive abnormality.
ETIOLOGY: 53

- Patient believes that he has serious disease
- Pain
- Patient comes with a detailed
pathophysiological model
explaining his symptoms

55
MANAGEMENT:
Hypochondraisis are one of the most difficult patient to
treat. It can be managed by general physicians. But
patient “Doctor Shopping” Behavior also elicits negative
reaction from the treating physician.
Basic principles of treatment are as follows:
- Treatment by a single physician
- Supportive approach & regularly scheduled visit
- Avoidance of hospitalization, diagnostic procedures &
medications with abuse potential
- Focusing on symptoms & brief examination in initial visit.

1. Flashbacks
2. Hyper vigilance
3. Avoidance
4. Numbness
TERMINOLOGIES RELATED TO PTSD:
56

PTSD is a set of reactions to an extreme stressor
such as intense fear, helplessness or horror that
leads individual to relieve the trauma.
5. POST- TRAUMATIC STRESS DISORDER
57

-Episodes of repeated relieving of the trauma
(“Flashbacks”) or dreams.
- Flashbacks occurring (against persisting background
of a sense of “numbness” and emotional blunting)
- Detachment from other people
- Unresponsiveness to surroundings
- Anhedonia

- 1-14% develop PTSD from a few week to months
- Rarely exceeds 6 months
INCIDENCE & ONSET OF SYMPTOMS:
59

- Evidence of trauma
- Onset within 6 months of a traumatic event
- Repetitive intrusive recollection
- Day time imagery or dreams
- Conspicuous emotional detachment
- Numbing of feeling
DIAGNOSTIC CRITERIA: 60

1. Stressor:
- Presence of childhood trauma.
- Borderline, Paranoid
- Antisocial personality disorder
- Inadequate support system
- Recent stressful life changes
2. Psychodynamic factors:
* Cognitive model composites that affected person are
unable to process, rationalize the trauma that precipitated
the disorder
* Behavioral model has two phases:
First the trauma, Second instrumental learning
ETIOLOGY:
61

3. Biological factors:
- Many neurotransmitter system have been responsible
for PTSD ( Nor epinephrine, Dopamine, Benzodiazepine
receptor and Hypothalamic- pituitary- adrenal axis)
ETIOLOGY:
62

63
MANAGEMENT:
PHARMACOLOGICAL TREATMENT:
- Antidepressants
- Fluoxetine
- Mood stabilizers (Reducing Dissociative & Numbing
Behavior)
- Antihypertensive (Propranolol or Clonidine)
- Anxiolytics (Clonazepam & Alprazolam)

Unit 8 neurotic stress and somatoform, PSYCHIATRIC NURSING

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Unit 8 neurotic stress and somatoform, PSYCHIATRIC NURSING