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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