NEUROSES

 Anxiety
 Obsessive compulsive
 Hysteria
 Reactive depression

ANXIETY DISORDERS

Introduction

Anxiety disorders, as seen earlier, come about as a result of reaction to stress. The symptom of
anxiety is found in many disorders, that is, mental, emotional and physical conditions. In the
anxiety disorders, which includes generalized anxiety, phobia, obsessive compulsive neurosis,
hysteria and reactive depression it is the most severe and prominent symptom.

DEFINITION-

Anxiety disorders (anxiety states) are abnormal states in which the most striking features are
mental and physical symptoms of anxiety, occurring in the absence of organic brain disease or
another psychiatric disorder.

SYMPTOMS OF ANXIETY

Psychological arousal

 Fearful anticipation
 Irritability
 Sensitivity to noise
 Poor concentration
 Worrying thoughts

Autonomic arousal

 Gastrointestinal
o Dry mouth
o Difficulty in swallowing
o Epigastric discomfort
o Excessive wind
o Frequent or loose motions

 Respiratory
o Constriction in the chest
o Difficulty inhaling
 Cardiovascular
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 o Palpitations
o Discomfort in the chest
o Awareness of missed heartbeats
 Genitourinary
o Frequent or urgent micturition
o Failure of erection
o Menstrual discomfort
o Amenorrhoea

Muscle tension

 Tremor
 Headache
 Aching muscles

Hyperventilation

 Dizziness
 Tingling in the extremities
 Feeling of breathlessness

Sleep disturbance

 Insomnia
 Night terror

Anxiety presents in the following way:

 Generalized anxiety disorders – anxiety is continuous
 Phobic disorders – anxiety intermittent, comes up in particular circumstances
 Panic disorder – anxiety intermittent but its occurrence is unrelated to any particular
circumstances.

GENERALISED ANXIETY DISORDER

1. Chronic
2. Common
3. Not restricted to specific situations
4. Psychological & physical symptoms present (see above)
Clinical Features
a. Anxious looking person
b. Pale
c. Sweating
d. Restless
e. May be close to tears

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 Prevalence – 4%

Aetiology : BIOPSYCHOSOCIAL
 Genetic
 Biochemical – imbalance of serotonin and gamma-amino butyric acid (GABA)
 Stressful events – childhood and current
 Result of abnormal cognitions – focus on worrying thought, anxious-avoidant
personality disorders

PHOBIC ANXIETY DISORDERS

This is anxiety that occurs in specific situations. It leads to anticipatory anxiety e.g. Patient may
feel anxiety even before they face the feared stimulus. Stimuli can be situations, e.g. Crowded
places, heights, illness phobia, flying phobia, dental fear, fear of choking or objects e.g. Snakes,
blood, spiders, insects etc
There are 3 main types:
1. Specific phobia
Anxiety of various objects. May be anticipatory anxiety. May lead to avoidance of the feared
object.
Anxiety with objects e.g. Snake, blood, dental fear, fear of choking, flying phobia, illness phobia.
More common in women and childhood than in men.

Etiology
 Persists from childhood
 Genetic
 Conditioning
 Innate

More women than men.

Common in childhood

Aetiology
 May persist from childhood
 Genetic
 Conditioning – learn from bad experience
 Innate, eg. Fear of snake instinctive fear that protects
 Check for illnesses such as depression / obsessive compulsive disorder

2. Social phobia
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This is increase of anxiety when a person is in a situation where they feel observed or where
they can be criticized. Fear of negative evaluation may lead to avoidance of social situations and
may stay away from places where there are people. May have anticipatory anxiety. May have
groundless fear of being observed critically. May drink alcohol to compensate. May be
depressed, suicidal.

Differential diagnosis
Distinguish from schizophrenia, avoidant personality disorder where there is life long shyness.
Distinguish from social inadequacy where there is failure of social skills. Present in men &
women equally.
Aetiology
May run in families
Conditioning (learn anxiety from past experience)
Cognitive abnormalities – excess worry of being criticized
Begins in adolescence. Tends to persist

3. Agoraphobia
Definition of agoraphobia
These people are anxious when away from home, in crowds, or in situations that they cannot
leave easily. Panic attacks may occur. Avoidance behaviours of situations far from home,
confinement, crowding (where they feel they cannot leave easily when they feel a panic attack
coming on). May be able to go out with family / close friends only. Anticipatory anxiety may be
present. May be depression, depersonalization, and obsessional thoughts. Begins in twenties /
thirties. Chronic condition. Usually women more than men.
Aetiology
Genetic
Cognitive distortions
Conditioning
Dependent personalities
It can lead to avoidance of the feared thing.

PANIC DISORDER
Definition
Recurrent attack of very severe anxiety and panic. Physical symptoms prominent.
Mental symptoms – fear of stroke, heart attack, fainting, dying, and going mad.
Lasts for about 20-30 minutes. May be hyperventilation – rapid breathing with physical
consequences (headache, dizziness, weakness, faintness, pins and needles in feet, hands and
round mouth). Anxiety builds up quickly, severe response and fear of catastrophic outcome.
May be anticipatory anxiety.
Women more than men.
Aetiology
Hyperventilation may be cause in itself
Cognitive theory – physical symptoms lead to abnormal cognitions e.g. Fast heart rate – people
feel they may have heart attack.
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TREATMENT OF ANXIETY DISORDERS
BIOLOGICAL TREATMENT
Treat any physical illness as well as other psychiatric illnesses and substance abuse.
For intense short term anxiety benzodiazepines such as diazepam 5mgs bid to tds may be used
but advice pt of risk of dependency and tolerance, so don’t use longer than a few weeks.
In chronic cases use antidepressants such as fluoxetine. Beta blockers like propranolol 40mgs
BD can be used for the physical somatic symptoms of anxiety. Advice to minimize caffeine and
alcohol (cause they are stimulants).
PSYCHOSOCIAL TREATMENT
Address any practical problems with housing and money. See what the anxiety may be about,
such as worry about physical illness.
Problem solving – look at each problem one by one with pt.
Counselling and reassurance
CBT – used to deal with anxiety.
E.g. In panic disorder talks to pts about symptoms such as hyperventilation, dizziness & heart
palpitation. Ask if they feel that they are going mad, having a stroke or a heart attack. Even
asking this question makes pts realize that their symptoms are known and not going to result in
their worst fears. If breathing too fast explains that this can cause changes in the body with
anxious feelings or pins and needles. If palpitations explain that this is from anxiety and not a
sign that they are having a heart attack. This can be very assuring for the pt.
BEHAVIOURAL TREATMENTS
In agoraphobia get the pt to talk about their anxieties about going out. Talk to them about their
hierarchy of fears. Going out to shops for example. Teach relaxation techniques such as
breathing exercises as well as sequential muscle relaxation technique. (This is getting the pt to
imagine a relaxed scene and at the same time to focus on relaxing muscles after tensing
muscles first-about 10-15 minutes. Get pt to go out for longer periods with each stage.
Systemic desensitization, observation, Flooding in association with Relaxation techniques :
Deep breathing exercises, Muscles relaxation exercises done
Panic attacks – Find cause of anxiety. Work on a behavioural programme using ABC –
antecedents, behaviours, and consequences. If hyperventilating pt can use paper bag by
breathing into bag.
Phobia – exposure with systemic desensitization E.g. Snake phobia expose to pictures and then
real, or imagined with increasing hierarchy of fears with matching relaxation
Agoraphobia – Need to get back to feared situation. Exposure
Treatment with anxiety management e.g. relaxation techniques, exposure, breathing exercises.
Cognitive Therapy – change way of thinking.

OBSESSIVE COMPULSIVE DISORDER

Definition – Feeling of compulsion to carry out some action, dwell on an idea or ruminate on an
idea. Pt realizes the thoughts are nonsensical and tries to put them out of mind but they keep
coming back. Can be thoughts of:
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  Contamination by germs
 Intrusive recurrent thoughts of violence to others
Pt. knows thoughts come from themselves and don’t make sense but they still can’t stop
and have associated anxiety.
Often in obsessional personality
An obsessional disorder consists of thoughts and rituals.
Obsessional Ruminations – urges to perform acts of a violent or sexual (psychosexual
disorders) or embarrassing nature. Risk of acting on this is rare. People may avoid places e.g. If
violent impulses of killing with knives may avoid kitchen.
Obsessional Rituals – includes mental activity such as counting, repeating words, or actions
such as hand washing. E.g. May spend hours washing or dressing themselves each day. May be
linked to obsessional thoughts e.g. a pt may feel that doing something a certain no. of times will
prevent bad things happening. If rituals / impulses etc are not completed in usual way there can
be anxiety and a compulsion to repeat actions which can be overwhelming and distressing.
Reassure pt by telling them what this is, and that they are not mad.
Obsessional slowness – Excessive slowness due to obsessions.
Men = Women
Aetiology
Can be a normal experience.
Genetic
Cognitive distortions
May be aggravated by stress
Some brain infections resulting into abnormal brain activity
TREATMENT
Drugs
Antidepressants
Psychological – Behavioural – prolonged, graduated exposure in real life to feared situations
combined with self-imposed response prevention. Response prevention means reducing the
rituals when a person is compelled to do them.
Harder to treat obsessional thoughts – Thought stopping e.g. Tell people to think something
else when they have obsessions or other stimulus.

Post-Traumatic Stress Disorder

Definitions
1. Intense, prolonged and delayed reaction to an intensely stressful event following
trauma. E.g. War, natural disaster, rape, assault, car accident.

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 2. Post-Traumatic Stress Disorder, mental illness that some people develop after
experiencing traumatic or life-threatening events. Such events include warfare, rape and
other sexual assaults, violent physical attacks, torture, child abuse, natural disasters
such as earthquakes and floods, and automobile or airplane crashes. People who
witness traumatic events may also develop the disorder.
3. Post-traumatic stress disorder in war veterans is sometimes called shell shock or combat fatigue.
In victims of sexual or physical abuse, the disorder has been called rape trauma or battered
woman syndrome. The American Psychiatric Association (APA) adopted the current name of the
disorder in 1980.

SYMPTOMS
1. People with this disorder relive the traumatic event again and again through
nightmares and disturbing memories during the day.

2. They sometimes have flashbacks, in which they suddenly lose touch with reality and
relive images, sounds, and other sensations from the trauma.

3. Because of their extreme anxiety and distress about the event,

4. They try to avoid anything that reminds them of it.

5. They may seem emotionally numb, detached, irritable, and easily startled.

6. They may feel guilty about surviving a traumatic event that killed other people.

7. Other symptoms include trouble concentrating,

8. Depression

9. Sleep difficulties.

OTHER EFFECTS OF PTSD

1. Symptoms of the disorder usually begin shortly after the traumatic event,
although some people may not show symptoms for several years. If left
untreated, the disorder can last for years.
2. Post-traumatic stress disorder can severely disrupt one’s life. Besides the
emotional pain of reliving the trauma, the symptoms of the disorder may cause a
person to think that he or she is “going crazy.”

3. In addition, people with this disorder may have unpredictable, angry outbursts at
family members.

4. At other times, they may seem to have no affection for their loved ones. Some
people try to mask their symptoms by abusing alcohol or drugs leading to Drug
Dependence.

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 5. Others work very long hours to prevent any “down” periods when they might relive the
trauma. Such actions may delay the onset of the disorder until these individuals retire or
become sober.

PREVALENCE

Studies have found from 1 to 14 percent of people suffer from post-traumatic stress disorder at some
point during their lives. The findings vary widely due to differences in the populations studied and the
research methods used. Among people who have survived traumatic events, the prevalence appears to
be much higher. The disorder may be particularly prevalent among people who have served in combat.
For example, one study of veterans of the Vietnam War (1959-1975) found that veterans exposed to a
high level of combat were nine times more likely to have post-traumatic stress disorder than military
personnel who did not serve in the war zone of Southeast Asia.

CAUSES
1. Post-traumatic stress disorder is an extreme reaction to extreme stress. In moments of
crisis, people respond in ways that allow them to endure and survive the trauma.
Afterward those responses, such as emotional numbing, may persist even though they
are no longer necessary.
2. Not everyone who experiences a traumatic event develops post-traumatic stress
disorder. Several factors influence whether people develop the disorder. Those who
experience severe and prolonged trauma are more likely to develop the disorder than
people who experience less severe trauma. Additionally, those who directly witness or
experience death, injury, or attack are more likely to develop symptoms.
3. People may also have existing biological and psychological vulnerabilities that make them more
likely to develop the disorder. Those with histories of anxiety disorders in their families may
have inherited a genetic predisposition to react more severely to stress and trauma than other
people. In addition, people’s life experiences, especially in childhood, can affect their
psychological vulnerability to the disorder. For example, people whose early childhood
experiences made them feel that events are unpredictable and uncontrollable have a greater
likelihood than others of developing the disorder. Individuals with a strong, supportive social
network of friends and family members seem somewhat protected from developing post-
traumatic stress disorder.

V TREATMENT

Treatment of post-traumatic stress disorder may involve psychotherapy, psychoactive

drugs, or both. Psychotherapists help individuals confront the traumatic experience,
work through their strong negative emotions, and overcome their symptoms. Many
people with post-traumatic stress disorder benefit from group therapy with other
individuals suffering from the disorder. Physicians may prescribe antidepressants or

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 anxiety-reducing drugs to treat the mood disturbances that sometimes accompany the
disorder.

The clinical features of PTSD can be divided into 3 groups:

Hyperarousal – Initial reaction to stress (alarm reaction) is exaggerated, leading to:

 Persistent anxiety
 Insomnia
 Irritability
 Poor concentration
Intrusions – re experiencing of aspects of the stressful events
 Nightmares
 Flashbacks – re experiencing of stressful event
 Intense intrusive imagery
Avoidance of reminders
 Difficult recalling stressful events at will
 Including avoidance of any reminders of the events
 Numbness and inability to feel emotions
 Decreased interest in activities
 Detachment
Other features
 Depression
 Guilt feelings e.g. Survivor guilt
 Depersonalization
 Dissociative symptoms
 Personality changes in some

A person with PTSD may use maladaptive responses to cope with the above symptoms. These
are alcohol use, aggression, drug use, self harm & suicide. Seen in war veterans.
Symptoms of PTSD may begin very soon after the stressful event or after some days and may be
followed by numbness for days to up to 6months. Triggers such as reminders may re activate.
Most cases resolve within a few months but if persists can be chronic up to some years.
Aetiology
Genetic vulnerability
Children, women, older
Imbalance of noradrenaline
Personality vulnerabilities
Fear conditioning
Cognitive distortions

TREATMENT
Drugs – antidepressants, anxiolytics
Psycho education about the condition and physiological responses.
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Look at triggers, anger management, cognitive re structuring
In acute phase provide emotional support, encourage recall of events in supported way
(FLOODING)

GRIEF (check with Kubler Ross stages of grieving)

Definition of grief
It is an emotional and behavioural response to bereavement or loss.
Mourning – Social manifestation of bereavement.

Abnormal grief – intense or prolonged, delayed or inhibited. Abnormal if longer than 6 months.
The grief is delayed if no symptoms 2 weeks after loss. Often behaviours of avoidance.
Depressed symptoms common and depression illness 1/3. Suicide risk increased after death of
spouse for up to 5 years, especially in the 1st year.
Abnormal grief more likely if death unexpected or traumatic, ambivalent relationship with
deceased, psychological difficulties, having dependent children.
Increased rates of death in surviving spouse – natural and suicide cases.

MANAGEMENT OF GRIEF
Usually no intervention required.
Counselling through loss. Explain grief process. Work on acceptance of loss, stages of grief,
adjust to new life. Mourning rituals help. In the case of a still birth allow parents to view and
grief. If extreme anxiety use medicines for depression or sleep agents in initial stage and anti
anxiety medicines for a limited period.
Guided mourning – stop avoidance behaviours, exposure treatment, get to face memories and
loss.

READ ON ACUTE STRESS REACTION / ADJUSTMENT DISORDER. Find out the difference between
this and POST TRAUMATIC STRESS DISORDER

RESPONSES OF THE BODY AND MIND TO STRESS

INTRODUCTION
Many scientists believe that all illness, has a physical and psychological component to it. E.g.
Physical disorders have a psychological component and mental disorders a physical one. Due to
this relationship between the mind (psyche) and body (soma), there is now a renewed interest
in holistic health practices (e.g. individualized / total nursing care involving the entire person,
i.e., biological, psychological, social-cultural and spiritual aspects).
For instance, in stress (psychological factors), adaptive coping in the stage of resistance can lead
to the body resisting a stressor thereby maintaining health. However, when adaptive
mechanisms become worn out and then fail, the stage of exhaustion comes in when the
negative stressor spreads to the entire organism. This results in physical conditions such as
migraine, hypertension, arthritis, hyperventilation, anorexia nervosa, peptic ulcer, obesity,
tension headaches, angina, eczema, impotence, frigidity, premenstrual syndrome, but to
mention a few. Stress may also lead to physical symptoms without any organic abnormality,
which is called somatoform disorders.
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Somatoform disorders
It is when one has physical symptoms without any organic impairment. These include:
 Somatization disorder
 Conversion or dissociative disorder (Hysteria)
 Hypochondriasis
 Body dysmorphic disorder
 Pain disorder

CONVERSION DISORDER OR HYSTERIA

Conversion is the term used to replace the older term hysteria. Also known as Dissociative
Disorder. In this condition the pt obtains relief by the conversion of mental distress into
physical symptoms, thus avoiding unwanted responsibilities, release from unpleasant
situations, a form of attention and manipulating others.
Definition of Conversion disorder
It is a somatoform disorder in which symptoms of some physical illness appear without any
underlying organic cause.
Symptoms might include any of the following
Sensory symptoms – numbness, blindness, deafness
Motor symptoms – paralysis, tremors, mutism
Visceral symptoms – urinary retention, headaches, or difficulty breathing
Seizures or convulsions with voluntary motor or sensory components

TREATMENT
 Assess pt thoroughly (physical and psychiatric history & examination, investigations)to
exclude organic and other psychiatric disorders & treat if present
 Reassurance
 Immediate efforts to resolve stressful event that provoked reaction
 Physiotherapy to enable return to normal physical functioning
 Remove any factors reinforcing disorder such as directing attention from symptoms and
towards problems that have provoked disorder
 Show concern for pt. but at the same time encourage self help e.g. A pt who cannot
walk should be encouraged to do so rather than providing them with a wheel chair.
 Measures to reduce symptoms should be accompanied by assistance with any personal
or social difficulties.
 Brief and focused psychological treatment – This kind of psychotherapy seeks to
uncover the origins of the conversion disorder in early life experiences, through any
unconscious factors that could have led to the abnormal behavior, emotions and
thinking. It is focused on specific problems. The therapist sees pt in a number of
sessions, once per week. During this time the therapist helps pt find their own solutions
to their problems. Not to do it for them.

REACTIVE DEPRESSION

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In the past, depression has been classified according to a no. of approaches which are:
 Presumed aetiology
 Symptoms
 Course
Classification of depression according to presumed aetiology has been found to be
unsatisfactory and is therefore not contained in both 1CD 10 and DSM IV.
Instead classification of depression is done by symptomatic picture and course.
Classification by presumed aetiology was divided into two types:
1. Endogenous depression – symptoms were caused by factors within the individual,
and were not due to outside factors.
2. Reactive depression – symptoms were a response to external stressors.
Reactive depression was also regarded as a neurosis because if a person had it, there was no
loss of insight (i.e. They knew they were sick with depression).

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