1. 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: N.Buttan@nhs.net, Naresh.Buttan@pcmd.ac.uk N.Buttan@nhs.netNaresh.Buttan@pcmd.ac.ukN.Buttan@nhs.netNaresh.Buttan@pcmd.ac.uk

2. Neurotic Disorders- Scene Setting RCPsych ILOs  1, 2: Identify, diagnose & formulate  3, 4, 5: Investigate, Manage & Refer 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 1 st & 10 for right & - 5 for wrong

3. Neurosis/Anxiety- Concept Neurosis/ Anxiety ? Worry (N, Webster/ Oxford Dictionary) Stress Normal vs. abnormal State vs. trait Episodic vs. Pervasive Situational vs. Generalized Internal (Active) vs. Reactive

4. Anxiety (Neurotic) Disorders: Relevance Prevalence: General Population ‘Symptoms- common in gen. population High Comorbidities May present with physical symptoms Proper recognition for appropriate treatment Management- combined approach Disorder Prev. 6/12 Rates % Lifetime Rates % Schizophrenia0.91.5 Affective Dis. 5.88.3 D & A dis 6.016.4 Anxiety Dis 8.914.6

5. Anxiety (Neurosis)- History Greek: 3 Humors Dark age: spirits/ divine punishments ‘Hysteria’ – Hippocrates (15 th -16 th 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’

6. 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

7. Anxiety (Neuroses)- Present Early Adverse Life Experiences. Genetic Predisposition Bio. VulnerabiltyPersonality/ Temperament Traumas/ SLEs D & A Physical Illnesses Bio. Changes in Brain Fn. Anxiety symptoms

8. Natural/ Environmental Blood/ Injury/ Injection Animal Other Anxiety Disorders GADPanicPhobicPTSDOCD Simple/ Sp.Compd./Gen. AgoraphobiaSocial Phobia

9. 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

10. 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, MMSE- 27/30-recall*

11. Case 1… Gp 1: Diagnoses/ differentials Gp 2: Aetiology Gp 3: Treatments Gp 4: Risks/prognosis

12. 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

13. 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

14. 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)

15. GAD- Treatments  Psychological: less effective than in other anxiety disorders, CBT useful- education, cognitive remediation. BT- exposure, relaxation, control of hyperventilation.  Physical: ECT/ Psychosurg.- rare (severe intractable)  Pharmacological: directed towards symptom domains: a)Psychic- buspirone b)Somatic- benzos c)Depressive- TCAs, SSRIs, SNRIs, Mirtazepine, MAOIs d)ANS/CVS- β blockers

16. 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

17. 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

18. Case 2 Gp 2: Diagnoses/ diffrertials Gp 3: Aetiology Gp 4: Treatments Gp 1: Risks/prognosis

19. Obsessive Compulsive Disorders Essence: a common chronic condition with obsessions &/or compulsions causing severe distress. Clinical features: ObsessionsCompulsions a) Recurrent, persistent, intrusive, irrational thoughts/ impulses/ images causing severe anxiety b) Person attempts to ignore/ suppress/ neutralize with some other thoughts or actions. Ownership maintained- not alienation a) Repetitive behaviours/ mental acts in response to obsession or according to strict rules b) Behaviours/ mental acts aim at preventing/ reducing distress or dreaded outcomes

20. 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.

21. OCD- Mx….. A Psychological: 1)Supportive: valuable, family, groups 2)BT: ERP, Thought stopping (ruminations) 3)CBT: Not proven effective, RET B Pharmacological: a)SSRIs: 1 st 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)

22. 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/SPECT- hypermetabolism in orbitofrontal gyrus & BG 4)Genetic: MZ: DZ= 50-80:25%, 3-7% 1 st degree relatives 5)Psychological: Defective arousal & / or inability to control unpleasant, obsessions -conditioned stimuli, compulsions- reinforced learned behaviours 6)Psychoanalytical: regression, isolation, undoing & reaction formation

23. OCD……. 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.

24. 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

25. 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.

26. Case 3… Gp 3: Diagnoses/ differentials Gp 4: Aetiology Gp 1: Treatment Gp 2: Risks/prognosis

27. Post Traumatic Stress Disorder (PTSD) 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: 1.Initial/ middle insomnia 2.Irritability/ anger outbursts 3.Poor concentration 4.Hypervigilance 5.↑sed startle response

28. 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

29. 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…..

30. 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

31. 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

32. 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 1

33. 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 2.

34. 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 MCQ 3.

35. Answers Q1. C Q 2. B Q 3. B

36. Thank You & Best Wishes ! Further reading Oxford Textbook of Psychiatry, 5 th 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, 10 th Ed, Taylor D, Paton C & Kapur S, Informa Healthcare 2009