Psychosis and Neurosis (Psychosis (Symptoms (Hallucinations
Psychosis and Neurosis
ICD 10 Neurotic stress related and somatoform disorders
• F40 Phobic anxiety disorders
• F41 Other anxiety disorders including GAD, panic disorder, mixed anxiety and depressive disorder
• F42 Obsessive compulsive disorder
• F43 Reaction to severe stress and adjustment disorders includes PTSD
• F44 Dissociative (conversion)disorders
• F45 Somatoform disorders
• F48 Other neurotic disorders (includes neurasthenia and depersonalisation derealisation syndrome)
Anxiety DisordersAnxious apprehension and worry in the absence of a realistic focus for the concern (.in ICD 10)
- Generalised anxiety disorder (GAD)
- Panic disorder
- Social phobia
- Specific phobias
What is anxiety?
- Set of physiological symptoms caused by overactivity of the sympathetic nervous system.
- Distorted and pathological cognitions involving excessive worry focused on unrealistic threats and unrealistic fear.
- NB Anxiety is normal and can be adaptive precedes fight or flight response.
Symptoms of Anxiety I
- Cognitive: Anxious ruminations
- Autonomic symptoms of anxiety: Palpitations, tachycardia, paraesthesiae, dizziness, cold clammy hands, sweating, hot and cold spells, frequency of urine, diarrhoea, nausea, and blepharospasm. Increased muscle tone producing: Shakiness, tremor, trouble swallowing, lump in throat, muscular aches, excessive tiredness. These symptoms can be worsened by hyperventilation, which can also lead to dizziness, perioral and limb paraesthesiae, and muscular spasm.
Symptoms of Anxiety II
- Hyper vigilance
- Irritability, onset insomnia, trouble staying asleep, easily startled, poor concentration, feelings of being keyed up or on edge (.having constant muscle tention – hence why constantly tired)
- Behavioural: Avoidance of anxiety provoking stimuli, often leading to social isolation (.often gerenarlise to other situations)
- Social phobia-Lifetime rates from 2.4% to 13.3% Yearly prevalence 9%. Onset early in life.
- Specific phobias-lifetime prevalence 11%, Yearly prevalence varies between studies around 8%. F:M 2:1. Common in children but don’t usually persist.
- Panic disorder/agoraphobia- Life time prevalence of panic disorder 1.5-2.5%. Yearly prevalence 1%. Much higher in clinical populations. Commoner in women 3:2 or 3:1 in some samples with average age of onset 18-35.
- GAD-Figures vary lifetime prevalence 5-10%. Yearly prevalence about 3%. Commoner in women 2:1.
Anxiety disorder types
Generalised Anxiety Disorder
- Persistent anxiety that is generalised. I.e. not linked to any particular situation “free floating anxiety”.
- Anxious cognitions. Anxious foreboding (horribly sense of something is going to happen, but not knowing what..)
Panic disorder symptoms
- discrete attacks of panic, which are not consistently associated with particular situations.
- A panic attack is a sudden onset of severe anxiety with somatic and cognitive symptoms. Patients often fear they are going mad, or are about to have a heart attack or die. Onset abrupt and peaks in minutes. Lasts from minutes to hours and gradually resolves.
- There is a 90% overlap between panic disorder and agoraphobia
Phobic anxiety disordersDisorders in which anxiety is triggered only or mainly in well defined situations, avoidance occurs. Panic attacks often occur.
- Agoraphobia -anxiety away from home in places which are difficult to leave quickly-crowds, public transport, cinema, etc.
- Social phobia-Fear of scrutiny by other people leading to avoidance of social situations.
- Specific phobias-Anxiety symptoms restricted to highly specific situations e.g. animals (commonly spiders, snakes), thunder darkness.
Anxiety Disorders-Differential Diagnosis
- Depression (note co morbidity common 66%).
- Other neurotic disorder e.g. alcohol, OCD, somatoform disorder. Co morbidity common, elicit all symptoms and decide which predates others, or is most prominent.
- Drug or alcohol dependence-anxiety common in withdrawal states.
- Physical illness: hyperthyroid, phaeochromocytoma, hypoglycaemia.
- Side effects of medication-e.g. Beta sympathomimetics, SSRIs.
- Organic disorders-anxiety symptoms in early dementia.
- Psychotic illness, schizophrenia may present initially with anxiety symptoms.
Anxiety Disorders ManagementPsychological
- Simple explanation/symptom education and reassurance
- Self help groups/ literature.
- Anxiety management programmes-groups
- Cognitive Behaviour Therapy/Cognitive Analytic therapy.
- Behaviour Therapy particularly for phobias:
- Exposure to feared stimulus
- Systematic desensitisation
- Graded exposure
- Education of parents
- Family assessment and therapy
Depending on severity
- Antidepressants often helpful in GAD & panic disorder
- Tricyclic antidepressants (e.g. Imipramine)
- Selective serotonin-reuptake inhibitors (e.g. fluoxetine)
- Serotonin-Norepinephrine-Reuptake Inhibitors)
- Non-benzodiazepine Anxiolytic agents (buspirone)
- Benzodiazepines (e.g. lorazepam)
- GAD tends to be chronic: 15% recovery at a year. 27% at 3 years.
- Specific phobias in childhood usually resolve. In adulthood tend to be chronic but treatment success rates are high.
- Social phobia chronic disorder, but individuals can be helped to cope.
- Agoraphobia/panic chronic course with relapses and remissions if untreated. 5 year follow up 12% -30% recovery. With treatment 70% improve considerably.
Stress and Adjustment Disorders
- Cluster of symptoms usually anxious and depressive in type, plus the existence of a causative factor.
- Mixture of anxious and depressive symptoms following an unpleasant life event. Subjective distress and some impairment of social function. Usually self-limiting lasting a few weeks. In ICD definition adjustment disorders arise within a month of the stressful event and must not persist beyond 6 months after the stressor.
Post Traumatic Stress Disorder
- Prolonged or delayed reaction to an overwhelming stressor which would be stressful and threatening to anyone.
- Symptoms: vivid remembering “flashbacks”, vivid memories and recurring dreams/nightmares, distress in situations reminiscent of the stressor and avoidance of such situations. A sense of emotional numbness with loss of recall of parts of the event.
Symptoms of increased autonomic arousal, hyper vigilance, and often irritability and insomnia.
- 20-30% of accident victims, can be over half of those involved in major disasters. Comorbidity.
- Mild-watchful waiting in first month. More severe-Psychotherapy- Trauma focused cognitive therapy, victim support groups, and progressive desensitization. Eye Movement Desensitisation and Reprocessing (EMDR). Debriefing no longer recommended. Medication if psychotherapy declined: paroxetine has license for ptsd. Mirtazapine (nice guidelines). Short term hypnotics. NB importance of screening.
- Course is fluctuating and usually resolves but can become chronic. Stable premorbid personality and high level of functioning and good social support are good prognostic factors.
Obsessive Compulsive DisorderDefining feature is the experience of obsessional thoughts or compulsive acts.
- Obsessional thoughts: Stereotyped ideas images or impulses Usually unpleasant, resistence common. Often obscene, violent and repugnant but recognised as the patients own thought. Cf thought insertion in psychotic illness.
- Compulsive acts or rituals are repetitive acts rather than thoughts. e.g. hand washing. May reduce the anxiety associated with an obsessional thought.
- Prevalence: Rare about 1% in community studies. (.the full blown syndrome)
- But symptoms are common – 20% of psychiatric patients in primary care.
- M=F (equal prevalence)
- Onset usually in early adult life.
- Depression. Obsessional symptoms occur in 20% of primary depression.
- Other neuroses: anxiety disorders, eating disorders-food rituals common.
- Schizophrenia-obsessional symptoms occur in 4% of those with schizophrenia usually early in the illness.
- Organic brain disorders-repetitive acts-(perseverations), distinguish from compulsions.
- Biological Genetic contribution, and genetic link to Gilles de la Tourette syndrome. PET studies show increased activity in the cingulate region and heads of the caudate nuclei and orbital gyri (also found in Tourettes).
- Psychological: Obsessional personality type may precede onset of OCD but 33% of OCD patients do not have premorbid obsessional personality, patients with an obsessional personality more likely to develop a depressive illness than OCD.
- Medication: SSRI s, Clomipramine Psychological: Often in conjunction with medication. Behaviour therapy, response prevention and thought stopping. Cognitive behaviour therapy (CBT).
- Very variable, usually following a fluctuating course with relapses under stress. At one year ¼ are well, ½ are better and ¼ the same or worse.
Problems with terminology
- There is now evidence of organic abnormalities in neurosis.
- Neurosis is an out of date terminology.
- It has pejorative overtones. Stigmatising.
Old WHO definition
"Mental disorders without any demonstrable organic basis in which the patient may have considerable insight and has unimpaired reality testing , in that he usually does not confuse his morbid subjective experiences and fantasies with external reality. Behaviour may be greatly affected although usually remaining within socially acceptable limits, but personality is not disorganised.” WHO 1977
Origin of term
- The term was first used in the late eighteenth century by Thomas Cullen a physician. He used it to mean nerve disorder. His concept of neurosis included nervous disorders and symptoms that do not have a clear organic cause. Later Freud used the term Anxiety neurosis to describe mental illness or distress with extreme anxiety as the defining feature.
- There have been calls to abandon the term. It was dropped from DSM when the third edition was published, but it persists having clinical utility in identifying a broad group of non psychotic patients. Anxiety disorders and OCD were classified as neurosis.
- Neurosis is retained in ICD10 in the title of a whole section of disorders “Neurotic, stress related and somatoform disorders”.
- Generally refers to ‘non psychotic’
- Modern terminology for the same group is
Common Mental Disorder in contrast to
Severe Mental Illness i.e. psychosis
- Synonyms: Minor Mental Disorder in contrast to Major Mental disorder i.e. Psychosis.
Disorders generally included under neurotic
?(maladaptive behaviours eating disorders, self-harm, substance abuse) – not classified as neurotic disorders (but not psychotic disorders either)
- Depression (excluding psychotic depression or bipolar disorder)
- Anxiety disorders
- Obsessive Compulsive disorders
- Stress related or adjustment disorders
- Somatoform disorders
Characterics of Neurosis/Common mental disorder
- Common-community prevalence 15-20%, higher in medical settings, 20% of GP, consulters, up to 30% medical outpatients
- Hidden morbidity-Psychiatric disorder missed by doctors
- Syndromal diagnoses: symptom clusters
- Arbitrary cut off case/non-case or subclinical disorder
- Comorbidity common
- State vs trait (abnormal personality) (. Is it always the case, or is it “abnormal” for them – is it usual for them or not)
- Developmental-life course perspective (.depending on stress etc.)
Prevalence neurotic disorder UK (. At any point in time)
OPCS survey 1995
• Mixed anxiety/depressive disorder 7.1%
• Generalised anxiety disorder 3.0%
• Depressive disorders 1.7%
• Phobia 1.7%
• Obsessional neurosis 1.3%
• Panic disorder 0.8%
• Overall 15.6%
Epidemiological picture (opcs survey)
Those with neurosis more likely to be:
• Women (62% cf/vs 38%)
• Widowed, divorced or separated (15% cf 8%)
• Lone parents (10% cf 5%)
• Living in one person family units (18% cf 13%)
• People with no educational quals (35% cf 28%)
• Economically inactive (44% cf 29%)
• Living in rented accommodation (39% cf 25%)
• Living in urban areas (72 % compared with 65%)
- Common Mental Disorder is Common (.Neurosis)! especially in clinical populations.
- Hidden morbidity nb somatisers.
- It is not Minor mental disorder causes considerable suffering/disability
- Recognisable clinical syndromes with known aetiology, and prognosis.
- State vs trait. They can be distinguished from personality disorders
- They can be treated.
Origin of term
- The term was first used by a german physician Karl Friedrich Constatt in his 1841 medical handbook. He used the term as an abbreviation of "psychic neurosis,". At the time neurosis referred to any nervous system disease. Constatt was therefore referring to a symptom of brain disease. A man called Ernst von Feuchtersleben; used the term in 1845, in place of terms such as insanity and mania.
- The word psychosis originates from the Greek words for "psyche" meaning the soul and "osis" meaning abnormal condition. The term psychosis was also used to distinguish disorders of the mind from "neurosis," which was thought to affect the nervous system.
- Psychosis therefore became the new term for madness.
- Kraeplin widely regarded as the father of modern scientific psychiatry established what he called a “clinical” view of psychiatry. He introduced a syndromal system of classification.
- He was the first to split the previous unitary category of psychosis into two main subdivisions of Dementia Praecox (Later termed Schizophrenia by Bleuler in 1908) and Manic depressive Psychosis (wide group of mood disorders). (1899 in His psychiatric textbook). This division persists today in ICD10 and DSMV
- Most definitions of psychosis emphasise that there is loss of contact with reality e.g. through the patient experiencing delusions and hallucinations. Insight is lacking.
- Thought and behaviour can be severely disorganised. The person may act well outiside socially acceptable limits.
- UK OPCS survey 1997: 1 year prevalence functional psychosis 4 per 1000 (.much less common than neurosis)
- Chronic disorders with relatively low mortality
- Lifelong disability
- 25-50% of ALL UK hospital beds until 1990s – now 5-10%
- Schizophrenia 15/100,000 (.most common psychotic disorder)
- Affective psychoses 12/100,000 (.bipolar disorders)
- Schizoaffective psychoses
- Acute and transient psychoses
- Persistent delusional disorder
- Cycloid psychoses
- Induced delusional disorders
- Drug induced psychosis 3 per 100,000
- Organic psychosis-delirium /acute confusional state.
- Kraepelin 1899 divided functional cases into manic depression and “dementia praecox”
- Bleuler 1908 coined the term “schizophrenia”
- 1933: Kasanin described “schizoaffective”
- 1959: Kurt Schneider described what he called “1st Rank Symptoms” of schizophrenia (survived in to our diagnostic systems)
First Rank symptoms
- 1 Thought insertion
- 2 Thought withdrawal
- 3 Thought broadcast
- 4 Thought echo: echo de pensee and gedankenlautwerden
- 5 Delusional perception: bizarre delusion in response to real perception.
- Third person Auditory Hallucination: Running commentary & Voices arguing.
- Made feelings impulses and actions-arising without volition, outside patients control.
- Somatic passivity-bodily sensations in the absence of a stimulus (somatic hallucinations)
ICD-10-SchizophreniaEITHER: 1 or more of following
Exclude affective disturbance and organic disorder
- a) Thought echo, insertion, withdrawal, broadcast
- b) Delusions of control, somatic passivity, delusional perception
- c) 3rd person aud. halls.
- d) Bizarre delusions
OR: 2 or more of:
- a) hallucinations more than 1 month
- b) Incoherent speech due to thought disorder
- c) catatonia
- d) “Negative” symptoms (but must exclude depression or drugs)
- Peak onset 20’s early 30s. Tends to start earlier in men. Male15-25 . Female 25-35
- Incidence 3-5/1000
- Prevalence ~ 1%
- Lifetime risk ~ 1%
- Genders equally affected in some studies, others show M:F 2:1
- Season of birth effect (commoner in winter births)
- Urban > rural
- Varies between studies depending on defintions of disorder, gender and age of onset
- Textbooks often quoted law of thirds: 1/3 recover , 1/3 relapse and remit, 1/3 chronic deterioration. Not true.
- Majority of patients do show decline in function over time with accumulating negative symptoms.
- NB accumulating physical morbidity: weight, metabolic syndrome, cardiovascular disease.
- Suicide is common 1 in 10
- Around 4% forensic . Aggression/violence.
• Reduced life expectancy
- Twice the mortality of rest of the population due to physical conditions
- Later onset
- Rapid onset
- Mood symptoms
- No family history
- Rapid treatment?
- Early onset
- Insidious onset
- No trigger
- Negative symptoms
- Family history
- Delayed treatment
- Medication: Schizophrenia: antipsychotics mostly second generation atypical antipsychotics now. Antidepressants and mood stabilisers in affective psychoses.
- Psychological treatments: Evidence base greatest for CBT.
- Psychosocial interventions: occupational therapy, rehabilitation, social work input with housing work etc.
- Held with unusual certainty-beware challenging them (.patients can become hostile when believes are challenged)
- Arise from morbid internal processes-e.g. depressed or elevated mood.
- Evidence evinced for holding the belief is abnormal
- Not amenable to logic.
- In hallucinations there is a perception which is not based on any real external stimulus. Any modality, commonest auditory.
- Auditory hallucinations. Muffled noises, music or distinct voices. Voice may be identifiable.
How the voices are heard is important
- Second person. In severe depression voices are often second person and the content may be mood congruent. “you are useless, kill yourself” etc.
- Third person hallucinations in the absence of organic disease suggest schizophrenia. They may argue about the patient in the third person or form a running commentary e.g. He is opening the door now, he is going out”
- Visual hallucinations suggest organic conditions: acute brain syndrome, e.g. delirium, illicit drug use (e.g. amphetamines or LSD) or drug withdrawal e.g. delirium tremens. Occasionally occur in schizophrenia or manic depressive illness.
- May see small animals in confusional states.
- Lilliputian-small people seen
- Scenic or poly modal: common in Temporal lobe epilepsy
- Charles Bonnet syndrome-VH secondary to low vision.
- Psychosis is much less common than neurosis and is more dislocated from normal experience-delusions and hallucinations.
- Psychosis usually causes profound loss of everyday function but severe neurosis can do this.
- Patients are more likely to be hospitalised with psychosis.
- Some disorders occupy a borderline area between the two (psychosis and neurosis)