Neurotic disorders

Psychosis vs. NeurosisSpecifications Psychosis Neurosis

Genetic factors More important Less important

Stressful life events

More Less

Behavior Severely affected Not affected

Thinking and perception

Disturbed Not disturbed

Judgment Impaired Intact

Insight Lost Present

Drugs Major tranquilizers

Minor tranquilizers

ECT Very useful Not needed

Prognosis Bad Good

Neurosis are classified under F4 in ICD 10 F40-F49- Neurotic, stress related and somatoform

disorders F40 – phobic anxiety disorders F 41 – other anxiety disorders F 42 – Obsessive compulsive disorder F 43 – Reaction to severe stress and adjustment

disorders F 44 – Dissociative (conversion) disorder F 45 – Somatoform disorders F 48 – other neurotic disorders

Psychopathology Disturbances in serotonin,

norepinephrine and gamma aminobutyric acid (GABA) appear to be most significant.

Serotonin is thought to be decreased and norepinephrne is thought to be increased in anxiety disorders.

GABA is decreased in anxiety disorders , allowingfor increased cellular excitability.

Etiological factors Psychoanalytic theories Freud proposed that anxiety is a signal

to the ego to take defensive action against the “pressure” from within. If repression is unsuccessful as a defense, other defense mechanisms may result in symptom formation

Generalized Anxiety Disorders (GAD) It is an anxiety disorder that is

characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry

It is a common chronic disorder characterized by long lasting anxiety that is not focused on any one subject or situation.

Biological theories 1. Autonomic nervous system James Lange theory states that

subjective anxiety is a response to peripheral phenomena. Stimulation of autonomic nervous system causes cardio vascular, respiratory and GI symptoms

2. Norepinephrine (NE) Studies have found that, in patients with

panic disorder, - adrenergic agonists (isoproterenol) and - adrenergic antagonists (yohimbine) can produce frequent and severe panic attacks, conversely clonodine, an adrenergic agonist, reduces anxiety symptoms in some experimental and therapeutic situations

Environmental factors Trauma, stressful events, changing jobs

or schools GAD s worse during the period of stress Use and withdrawal from addictive

substances, alcohol, caffeine, nicotine etc can worsen anxiety

Epidemiology Onset is usually from childhood to late

adulthood Onset is approximately 31 More in women Common in elderly population also

symptoms Cardiovascular Tachycardia Chest pain Palpitations Flushing fainting

Respiratory Sighing Choking Yawning Dyspnoea

Alimentary symptoms Dry mouth Dysphagia Dyspepsia Butterflies in stomach Nausea Abdominal pain diarrhea

Genito urinary symptoms Frequency Hesitation Sexual dysfunctions Nerveous symptoms Tension headache Blurring of vision Tinnitus Tremor Dilated pupils

Musculo skeletal symptoms Aches and pains Teeth clenching Chronic jerks

Physiological symptoms Anxious mood Worry or fear Irritability Inability to relax Feeling of being unable to cope Feeling restless Depersonalization Initial insomnia Nightmare

Treatment Medication Benzodiazepines (valium, librium) Anti depressants (paxil, prozac, zoloft) TCA, SSRI Psychotherapy CBT Biofeedback Relaxation therapy Supportive therapy

Prevention Stop consuming products contain

caffeine Do not take OTC medicines Exercise daily and eat healthy diet Seek counseling help after traumatic

experience Practice stress management techniques

Panic disorder A sudden overwhelming feeling of terror

or impending doom. This severe form of emotional anxiety is usually accompanied by behavioral, cognitive and physiological signs and symptoms considered to be outside the expected range of normalcy

Classification F41.0 – panic disorder F41.1 – Generalized Anxiety Disorder F 41.2 – Mixed anxiety and depressive

disorder F41.9 – other specified anxiety disorders

Epidemiology Lifetime prevalence estimates range

from 1.5 – 5% for panic disorder and 3- 5.6% for panic attacks

Women are more likely to be affected than men by a 2-3 fold factor

Highest incidence is in late adolescence and second peak in mid 30s.

Causes Genetic factors (the concordance rate in

monozygotic twins of patients with panic disorder is 80%)

Biochemical factors (reduction in GABA activity in brain)

Malfunctioning of brain structure such as amyldala and hormonal/ adrenaline glands.

Co morbid condition with heridity disorders , such as bipolar disorder and genetic predisposition to alcoholism

Medical conditions like hypoglycemia, hyperthyroidism, mitral valve prolapse, labirinthitis and pheochromocytoma can aggravate panic disorder

Stressful life events, life transitions and environment play a role in the onset of panic disorder.

psychopathology Serotonergic model suggests an

exaggerated or inefficient post synaptic receptor response to synaptic serotonin

Catecholamine model postulates increased sensitivity to or improper processing of adrenergic CNS discharge, with potential hypersensitivity of presynaptic alpha-2 receptors

Lactate model focuses on symptom production by postulated aberrant metabolic activity induced by lactate.

GABA model postulates decreased inhibitory receptor sensitivity, with a resultant excitatory effect

Neuroanatomic model suggests panic attacks are mediated by a fear network in the brain that involves amygdala, hypothalamus and brainstem centers.

Clinical features Shortness of breath and smothering

sensations Pounding and rapid heart beat Palpitations Chocking, chest discomfort and pain Sweating, dizziness, unsteady feelings

or fainting Nausea or abdominal discomfort

Depersonalization or derealization Numbness or tingling sensations Flushes or chills Trembling or shaking Fear of dying or having heart attack Fear of being out of control,

agoraphobia, depression

Diagnostic criteria Recurrent unexpected panic attacks At least one of the attacks has been followed

by 1 month with the following• Persistent concern about having additional

attacks• Worry about implications of the attack or its

consequences• Significant change in behavior related to the

attacks• Presence or absence of agarophobia

Treatment Pharmacotherapy SSRI Benzodiazepines Sedating antidepressants (TCA) Lorazapam (Avitan) 0.5 -1 mg IV/ IM 1-

2mg PO bid/tid Clonazepam (Klonopin) 0.5-2mg PO

bid/tid

Psychotherapy CBT Psychodynamic psychotherapy Relaxation techniques Respiratory techniques Interoceptive training

Nursing management Panic anxiety Stay with client and offer reassurance Maintain a calm, non threatening,

matter of fact approach Use simple words and brief massages.

Keep immediate surroundings low in stimuli

Administer tranquilizing medication as ordered by physician

When level of anxiety has been reduced, explore possible reasons for re occurrence

Teach symptoms of escalating anxiety and ways to interrupt its progression

powerlessness Allow client to take as much responsibility as

possible for self care practices Provide client with privacy as needed Provide positive feedback on decisions made Assist client to set realistic goals Help identify areas of life situation that client

can control Encourage verbalization of feelings related to

inability

Phobia A phobia is defined as an irrational fear

that produces a conscious avoidance of the feared subject, activity or situation. The affected person usually recognizes that the reaction is excessive

Classification Agoraphobia Social phobia Specific phobia Other phobic anxiety disorders Phobic anxiety disorder, unspecified