Neurosis

Question 1

What is meant by neurosis?

Answer 1

A collective term for psychiatric disorders characterised by distress, that are non- organic, have a discrete onset and where hallucinations and delusions are absent.

Question 2

What is anxiety?

Answer 2

Unpleasant emotional state involving subjective fear and somatic symptoms

Question 3

What’s the Yerkes Dodson Law?

Answer 3

This states that anxiety is beneficial up to a plateau of optimal functioning. Beyond this level of anxiety then performance deteriorates.

Question 4

What are the symptoms of anxiety?

Answer 4

Psychological- anticipatory fear of impeding doom, worrying thoughts, exaggerated startle response, restlessness, poor concentration and attention, irritability, depersonalisation and de realisation.

Cardiovascular- chest pain and palpitations

Respiratory- hyperventilation, cough, chest tightness

GI- abdo pain, loose stools, N and V, dysphagia, dry mouth

Genitourinary- increased freq of micturition, failure of erection, menstrual discomfort

Neuromuscular- tremor, myalgia, headache, parasthesia, tinnitus

Question 5

What is the ICD-10 classification of anxiety disorders?

Answer 5

Phobic anxiety disorders- agoraphobia, social phobia, specific phobia

Other anxiety disorder- panic disorder, generalised anxiety disorder, mixed anxiety and depressive disorder.

Reaction to severe stress and adjustment disorders- acute stress reaction, post traumatic stress disorder, adjustment disorder.

Question 6

What are the clinical features of neuroses?

Answer 6

The previous symptoms mentioned
Associated cognitions- worried or fears that are inappropriate or excessive
Associated behaviours include avoidance of escape
Depressive symptoms are also common in neuroses

Question 7

What are the phobic anxiety disorder?

Answer 7

Specific phobia, agoraphobia, social phobia.

Question 8

What is generalised (free floating) anxiety?

Answer 8

Present most of the time and not associated with specific objects or situations. Excessive or inappropriate worry about normal life events. Typically longer duration (days, months or even years).

Question 9

What is episodic (paroxysmal anxiety) ?

Answer 9

Has an abrupt onset, occurs in discrete episodes. The episode of anxiety is severe with strong autonomic symptoms, but usually short lived (typically less than one hour). Can occur in response to specific threats.

Question 10

What are the common medical conditions associated with anxiety?

Answer 10

Hyperthyroidism, hypoglycaemia, anaemia, phaeochromocytoma, cushings disease, obstructive pulmonary disease (COPD), CCF, malignancies.

Question 11

What are the psychiatric conditions related to anxiety?

Answer 11

Eating disorders 
Somatoform disorders 
Depression 
Schizophrenia 
OCD 
PTSD 
Adjustment disorder 
Anxious (avoidant personality disorder)

Question 12

What are the substance related conditions associated with anxiety?

Answer 12

Intoxication- alcohol, cannabis, caffeine
Withdrawal- alcohol, benzodiazepine, caffeine
Side effects- thyroxine, steroids, adrenaline

Question 13

What is GAD?

Answer 13

Ongoing, uncontrollable widespread worry about many events or thoughts that the patient recognises as excessive and inappropriate. Symptoms must be present most days and for at least 6 months duration.m

Question 14

What are the predisposing, precipitating and perpetuating risk factors for GAD?

Answer 14

Predisposing: genetics, childhood upbringing, personality type and demands for high achievement, being divorced, living alone or as a single parent. Low socioeconomic status.

Precipitating: domestic violence, unemployment, relationship problems and personal illness (chronic pain, arthritis, COPD)

Perpetuating: continuous stressful life events.

Question 15

What are the clinical features of anxiety?

Answer 15

Worry which is excessive and uncontrollable 
Autonomic hyperactivity (sweating, increase in HR, increase in pupil size) 
Tension in muscles/ tremor 
Concentration difficulty/ chronic aches 
Headaches, hyperventilation 
Energy loss 
Restlessness
Startled easily/ sleep disturbance

Question 16

What is the ICD-10 criteria for GAD?

Answer 16

A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems.

At least four of the watcher symptoms and at least one autonomic arousal (palpitations, sweating, shaking/tremor, dry mouth)

Question 17

What are the investigations would you do for generalised anxiety?

Answer 17

Blood tests- FBC (infection/Anaemia), TFTS (hyperthyroidism), glucose (hypoglycaemia)

ECG- sinus tachycardia

Questionares- GAD 2, GAD7, Becks anxiety inventory, hospital anxiety and depression scale.

Question 18

What are the differentials for GAD?

Answer 18

Other neurotic disorders: Panic disorder, specific phobias, OCD, PTSD
Depression
Schizophrenia
Personality disorder (anxious PD, dependent PD)
Excessive caffeine or alcohol consumption
Withdrawal from drugs
Organic- anaemia, hyperthyroidism, hypoglycaemia

Question 19

What is the biological treatment for GAD?

Answer 19

SSRI (sertraline) is recommended which has anxiolytics effects
If the SSRI does not work then SNRI (venlafaxine, duloxetine) can be offered.

If both of the above can’t be tolerated then pregabalin may be used.

Meds should be continued for at least a year.

Question 20

Why shouldn’t benzodiazepines be used long term for GAD?

Answer 20

They can cause dependence.

Question 21

What are the psychological treatments of GAD?

Answer 21

Psycho educational groups (low intensity)

CBT and applied relaxation (high intensity)

Question 22

What are the social intervention management for GAD?

Answer 22

Self help methods- writing things down and analysing them and support groups. Exercise may also help

Question 23

What is the stepped care model proposed by NICE to determine the most effective interventions for patients with GAD?

Answer 23

Step 1= identification and Assessment. Psycho education about GAD and active monitoring.

Step 2= low intensity psychological interventions

Step 3= high intensity psychological interventions (CBT or drug treatment)

Step 4= highly specialist input (combination of drug and psychological therapies, involvement of crisis team, multi agency teams).

Question 24

What is meant by phobia?

Answer 24

An intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable.

Question 25

What is agoraphobia?

Answer 25

A fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack.

Question 26

What is social phobia (social anxiety disorder)?

Answer 26

A fear of social situations which could lead to humiliation, criticism or embarrassment.

Question 27

What is a specific (isolated) phobia?

Answer 27

A fear restricted to a specific object or situation.

Question 28

What are the risk factors for phobias?

Answer 28

``` Aversive experiences Stress and negative life events Other anxiety disorders Mood disorders Substance misuse disorders Family history ```

Question 29

What are the clinical features of phobic anxiety disorders?

Answer 29

Biological- tachycardia is the most common autonomic response, however in phobias of blood, injection and injury then bradycardia can be produced. Psychological- unpleasant anticipatory anxiety, inability to relax, urge to avoid the feared situation, and at extremes a fear of dying.

Question 30

What is the ICD-10 criteria of agoraphobia?

Answer 30

A. Marked and consistently manifest fear in, or avoidance of, at least two of the following... 1. Crowds 2. Public spaces 3. Travelling alone 4. Travelling away from home B. Symptoms of anxiety in the feared situation, with at least two symptoms present together (and at least one symptom of autonomic arousal) C. Significant emotional distress due to avoidance or anxiety symptoms. Recognised as excessive or unreasonable D. Symptoms restricted to (or predominate in) feared situation.

Question 31

What is the ICD-10 criteria of social phobia?

Answer 31

A. Marked fear/ avoidance of being the centre of attention or fear of acting in a way that will be embarrassing or humiliating. B. At least two symptoms of anxiety in the feared situation, plus one of the following... . Blushing . Fear of vomiting . Urgency or fear of micturition/defecation C. Significant emotional distress due to the avoidance of anxiety symptoms D. Recognised as excessive or unreasonable E. Symptoms restricted to (or predominate in) feared situation.

Question 32

What is the ICD-10 criteria for a specific phobia?

Answer 32

A. Marked fear (or avoidance) of a specific object or situation that is not agoraphobia or social phobia.m B. Symptoms of anxiety in the feared situation C. Significant emotional distress due to the avoidance or anxiety symptoms. Recognised as excessive or unreasonable. D. Symptoms restricted to the feared situations.

Question 33

What is the management of agoraphobia?

Answer 33

CBT- graduated exposure techniques | SSRIS are the first line pharmacological agent

Question 34

What is the management of social phobia?

Answer 34

CBT (individual or group) specifically designed for social phobia, graduated exposure Pharmacological interventions- SSRIs, SNRIs (venlafaxine), or if no response to these, MAOI (moclobemide) Physcodynamic psychotherapy for those who decline CBT or medication.

Question 35

What is the management of specific phobia?

Answer 35

The mainstay of treatment is exposure either using self help methods or more formally though CBT.

Question 36

What is panic disorder?

Answer 36

Characterised by recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.

Question 37

What are the most heritable anxiety disorder?

Answer 37

OCD and panic disorder.

Question 38

What are the aetiologie of panic disorder?

Answer 38

Genetics Neurochemical: post synaptic hypersensitivity to serotonin and adrenaline Sympathetic nervous system- fear or worry stimulates the SNS which can increase cardiac output and lead to further anxiety Cognitive- misinterpretation of somatic symptoms eg: fear that palpitations will lead to heart attack Environmental- presence of life stressors can lead to panic disorder

Question 39

What are the risk factors for panic disorder?

Answer 39

``` Family history Major life events 20-30 years Recent trauma Females Other mental disorders White ethnicity Asthma Cigarette smoking Medications eg: benzodiazepine withdrawal ```

Question 40

What is the ICD-10 criteria for the diagnosis of panic disorder?

Answer 40

A. Recurrent panic attacks that are not consistently associated with a specific situation or object and often occur spontaneously. The panic attacks are not associated with marked exertion or with exposure to dangerous or life threatening situations. B. Characterised by all of the following Discrete episode of intense fear or discomfort Starts abruptly Reaches a crescendo within a few minutes and lasts at least some minutes At least one symptom of autonomic arousal Palpitations Sweating Shaking Tremor Dry mouth

Question 41

What are the features of panic disorder?

Answer 41

PANICD ``` P= palpitations A= abdominal distress N= numbness/ nausea I= intense fear of death C= choking/chest pain S= sweating/ shaking/ shortness of breath D= depersonalisation/ derealization ```

Question 42

What is the difference between depersonalisation and derealisation?

Answer 42

Depersonalisation- feeling disconnected or detached from one’s self Derealization- mental state where you feel detached from your surroundings

Question 43

What is the management of panic disorders?

Answer 43

SSRIs are first line but they are not suitable or there is no improvement after 12 weeks, then a TCA eg: imipramine or clomipramine may be considered. CBT Self help methods including bibliotherapy, support groups and encouraging exercise to promote good health

Question 44

What is PTSD?

Answer 44

An intense, prolonged, delayed response to an exceptionally traumatic event.

Question 45

What is abnormal bereavement?

Answer 45

Has a delayed onset, is more intense and prolonged (>6months). The impact of their loss overwhelms the individuals coping capacity.

Question 46

What is an acute stress reaction?

Answer 46

An abnormal reaction to sudden stressful events.

Question 47

What is adjustment disorder?

Answer 47

Significant distress (greater than expected), accompanied by an impairment in social functioning when adapting to new circumstances.

Question 48

What is the most important component of aetiology of PTSD?

Answer 48

An exceptionally stressful event in which the individual was involved directly or as a witness.

Question 49

What are the risk factors of PTSD...

Answer 49

Exposure to a major traumatic event - certain professions Pre trauma: previous trauma, history of mental illness, females, low socioeconomic economic background, childhood abuse Peri trauma: severity of trauma, perceived threat to life, adverse emotional reaction during or immediately after an event. Post trauma: concurrent life stressors, absence of social support.

Question 50

What are the symptoms of PTSD?

Answer 50

PTSD symptoms must occur within 6 months of the event and can be divided into four categories... 1. Reliving 2. Avoidance 3. Hyperarousal 4. Emotional numbing

Question 51

What is the ICD-10 criteria for the diagnosis of PTSD?

Answer 51

A- Exposure to a stressful event B- Persistent remembering ‘reliving off the situation’ C- Actual or preferred avoidance of similar situations which either resemble or are associated with the stressor D- Either (1) or (2): 1. Inability to recall some important aspects of the period of exposure to the stressor 2. Persistent symptoms of increased psychological sensitivity and arousal Criteria B, C and D all occur within 6 months of the stressful event, or the end of a period of stress.

Question 52

What questionares can be used to screen for PTSD?

Answer 52

Trauma Screening Questionare | Post traumatic diagnostic scale

Question 53

What are the stages of grief?

Answer 53

``` DABDA Denial Anger Bargaining Depression Acceptance ```

Question 54

What is an acute stress disorder?

Answer 54

Exposure to an exception, physical or mental stressor followed by an immediate onset of symptoms (within one hour). It is divided into mild, mod, severe, based on the symptoms. Symptoms should diminish within 8 hours if it is an immediate stressor or 48 hours if it is a transient stressor.

Question 55

What is adjustment disorder?

Answer 55

Identifiable (non catastrophic) psychosocial stressors like redundancy and divorce within one month of onset of symptoms. Symptoms must be less than 6 months.

Question 56

What is the management of PTSD?

Answer 56

. Psychological intervention- CBT and eye movement desensitisation and reprocessing (EMDR) . SSRI= Paroxetine (weaker), atypical= mirtazapine, amitriptyline, phenelzine are licensed however amitriptyline and phenelzine are rarely used due to the side effects.

Question 57

What is obsessive compulsive disorder?

Answer 57

It is characterised by recurrent obsessional thoughts or compulsive acts, or commonly both.

Question 58

What is meant by an obsession?

Answer 58

UNWANTED INTRUSIVE thoughts, images or urges that repeatedly enter the individuals mind. They are distressing for the individual who attempts to resist them and recognises them as absurd.

Question 59

What are compulsions?

Answer 59

Repetitive, stereotyped behaviours or mental act that a person feels driven into performing.

Question 60

What is meant by covert and overt compulsions?

Answer 60

Covert- things you can’t see | Overt- observable by others

Question 61

What is the pathophysiology/aetiology of OCD?

Answer 61

Biological: related to decreased serotonin and abnormalities of the frontal cortex and basal ganglia Psychoanalytic’s- filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness. Behavioural- compulsive behaviour is learned and maintained by operant conditions.

Question 62

What are the risk factors for OCD?

Answer 62

More common in the relatives of OCD patients Carrying out the compulsive act is a maintaining factor Developmental factors- abuse, neglect, bullying, social isolation

Question 63

What are features of obsessions and compulsions. (FordcaR)

Answer 63

``` F= failure to resist O= originate from the patients mind R= repetitive and distressing C= carrying out the obsessive thought (or compulsive act) is not in itself pleasurable, but does reduce anxiety levels. ```

Question 64

What is an OCD cycle?

Answer 64

Obsessions create anxiety which continue to build until a compulsion is carried out in order to provide relief.

Question 65

What is the questionare used for OCD?

Answer 65

Yale Brown obsessive compulsive scale

Question 66

What is the management for OCD?

Answer 66

CBT SSRIs are the drug of choice, NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram Clomipramine can be added to citalopram in more severe cases. Alternatively an antipsychotic can be asses in with an SSRI or clomipramine

Question 67

What is a somatoform disorder?

Answer 67

Group of disorders where the symptoms are suggestive/take the form of a physical illness but in absence of physiological illness, leading to the presumption that they are caused by psychological factors.

Question 68

What are dissociative (conversion) disorders?

Answer 68

Characterised by symptoms which cannot be explained by a medical disorder and where there are convincing associations between a stressful event and symptoms.

Question 69

What is the pathophysiology of somatoform disorders?

Answer 69

Biological- possible implication of neuro endocrine genes. Studies show a genetic component Psychological- a high proportion of those with PTSD suffer from somatoform disorders There is an association between somatization and physical or sexual abuse Social- adopting of the sick role in order to release stress

Question 70

What is somatisation disorder?

Answer 70

This is also known as briquets syndrome | It is multiple, recurrent and frequently changing physical symptoms which are not explained by a physical illness.

Question 71

What are the features of somatization disorder?

Answer 71

At least 2 years duration Preoccupation with symptoms causing physical distress leading them to seeking repeated consultations and requesting investigations Continuous refusal to accept reassurance that there is no causes for their symptoms Total of 6 or more symptoms

Question 72

What symptoms do people with somatoform disorder present with?

Answer 72

GI: abdo pain, N&V, bloating, regurgitation, loose bowels, difficulty swallowing CVS: chest pain, breathlessness, palpitations Genitourinary- dysuria, frequency, incontinence, vaginal discharge, menstrual problems

Question 73

What is somatisation disorder?

Answer 73

This is also known as briquets syndrome | It is multiple, recurrent and frequently changing physical symptoms which are not explained by a physical illness.

Question 74

What are the features of somatization disorder?

Answer 74

At least 2 years duration Preoccupation with symptoms causing physical distress leading them to seeking repeated consultations and requesting investigations Continuous refusal to accept reassurance that there is no causes for their symptoms Total of 6 or more symptoms

Question 75

What symptoms do people with somatoform disorder present with?

Answer 75

GI: abdo pain, N&V, bloating, regurgitation, loose bowels, difficulty swallowing CVS: chest pain, breathlessness, palpitations Genitourinary- dysuria, frequency, incontinence, vaginal discharge, menstrual problems

Question 76

What is hypochondriacal disorder?

Answer 76

This is where patients misinterpret normal bodily sensations which leads them to non delusional pre occupation that they have a serious physical disease ie: cancer.

Question 77

What is dysmorphophobia?

Answer 77

This is also known as body dysmorphic disorder, it is where there is excessive preoccupation with a barely noticeable or imagined defect in their physical appearance. The pre occupation causes significant distress.

Question 78

What is somatoform autonomic dysfunction?

Answer 78

This is where symptoms are related to the autonomic nervous system, symptoms of autonomic arousal are attributed by patients to a physical disorder of one or more of the CVS, resp, GI, genitourinary.

Question 79

What is persistent somatoform pain disorder?

Answer 79

Persistent (6 months) and severe pain that cannot be fully explained by a physical disorder The pain usually occurs as a result of psychosocial stressors and emotional difficulties. It differs from somatization in that pain is the primary feature and multiple symptoms from different systems are not present.

Question 80

What is hypochondriacal disorder?

Answer 80

This is where patients misinterpret normal bodily sensations which leads them to non delusional pre occupation that they have a serious physical disease ie: cancer.

Question 81

What is dysmorphophobia?

Answer 81

This is also known as body dysmorphic disorder, it is where there is excessive preoccupation with a barely noticeable or imagined defect in their physical appearance. The pre occupation causes significant distress.

Question 82

What is somatoform autonomic dysfunction?

Answer 82

This is where symptoms are related to the autonomic nervous system, symptoms of autonomic arousal are attributed by patients to a physical disorder of one or more of the CVS, resp, GI, genitourinary.

Question 83

What is persistent somatoform pain disorder?

Answer 83

Persistent (6 months) and severe pain that cannot be fully explained by a physical disorder The pain usually occurs as a result of psychosocial stressors and emotional difficulties. It differs from somatization in that pain is the primary feature and multiple symptoms from different systems are not present.

Question 84

What are the differential diagnoses of somatoform disorders?

Answer 84

Dissociative Factitious disorder Malingering Multi systemic disease

Question 85

What is the management of somatoform disorders?

Answer 85

Biological therapies: antidepressants SSRIs Psychological therapies: CBT Social: can get family involved, encourage exercise, stress relief activities.