Disorders that take

several different
forms, but which are
all related to a
generalized feeling
of anxiety

Neurotic and Stress-related

Disorders
Neurotic and Stress-related
Disorders

Dr. S. K. Vijayachandran
 Anxiety in…
• Moderate amounts • Extreme amounts
– Adaptive/protective – Distracting
– Allows avoidance – Paralyzing
of real danger (e.g., – Debilitating
strangers) – Self-perpetuating
– Teaches coping (I.e., neurotic
– Allows enhanced paradox)
performance
 Anxiety vs. Fear
• Anxiety: • Fear:
– Future-oriented – Present-oriented
– Apprehension – Immediate alarm
– Dread to current danger
– Lack of control – “I have to do
– “something’s something
going to happen” NOW”
 Anxiety in Medical Patients
Characteristics that distinguish
• Anxiety out of proportion to the level of threat
• Persistence or deterioration without intervention
(> 3 weeks)
• Symptoms that are unacceptable regardless of
the level of threat, including
Recurrent panic attacks
Severe physical symptoms
Abnormal believes such as thoughts of sudden
death
• Disruption of usual or desirable functioning
 Presentations
• Abnormal anxiety can present with various
typical symptoms and signs, which include
– Autonomic over-activity, fight/flight
– Behaviors such as restlessness and
reassurance seeking – to fight or flee
– Cognitive - Changes in thinking, including
intrusive catastrophic thoughts, worry, and
poor concentration – search for threat
– Physical symptoms such as muscle tension
or fatigue.
 Physical
Symptoms
 ICD-10 Classification
Neurotic, Stress related and Somatoform
Disorders
• Phobic anxiety disorders • Reaction to severe stress
– Agoraphobia- without PD, and adjustment disorders
with PD – Acute stress reaction
– Social phobia – PTSD
– Specific phobia – Adjustment disorders

• Other anxiety disorders • Dissociative (conversion)

disorder
– PD
• Somatoform disorders
– GAD
– Somatization disorder
– Mixed anxiety and
– Hypochondrial disroder
depressive disorder
– Somatic aut. dysfunction
• OCD – Somatoform pain disorder
 Medical Conditions Mimicking or
Causing Anxiety Disorders
• Poor pain control • Anaemia
• Hypoxia –
asthma and pulm. Embolus
• Diabetes -
Anemia Hypoglycaemia  
Cardiac arrythmia • Hyperkalaemia 
MI     
• Hypocapnia- • Vertigo    
• Central nervous system disorders • Hypercapnia   
(structural or epileptic)   
CNS trauma • Hyponatraemia
Migraine
subarachnoid hemorrhage
• Pheochromocytoma
epilepsy (TLE)  • Alcohol or drug
withdrawal 
Treatment- ‘Fix’ the underlying problem
 Drugs
• Anticonvulsants • Digitalis At toxic levels   
-Carbamazepine, • Dopamine    
• Antidepressants - SSRI    • Oestrogen   
• Antimicrobials - • Inotropes Adrenaline,
Cephalosporins, ofloxacin,   noradrenaline 
aciclovir, isoniazid    • Insulin When
• Antihistamines     hypoglycaemic   
• Bronchodilators • Levodopa    
• Calcium channel   blockers   • NSAIDs- Indomethacin   
   • Corticosteroids   
• Thyroxine

Many drugs can cause palpitation or tremor, but these should be easily
distinguished from anxiety by clinical examination
General Management of Anxiety in
Medical Patients
• Giving information –
– first step - knowledge is reassurance. - tailored to the wishes of
the individual
• Effective communication –
– Anxiety is associated with poor communication - open questions,
discuss psychological issues, and summarize
– Avoid reassurance, "advice mode," and leading questions
• Reassurance
– Simple reassurance may be ineffective for anxious patients;
– their anxiety may be reduced initially by the consultation, but it
rapidly returns.
– Several theoretical models of this problem- cognitive model
 Substance-Induced Anxiety
Disorder
• Anxiety occurs during, or within one month
of, substance intoxication or withdrawal
• Alcohol
• Stimulants: amphetamine, cocaine,
caffeine
• Inhalants: solvents, glue, gasoline, paint
• Prescription drugs:
 GAD
Generalized Anxiety
Disorder
 GAD
• Prevalence in general population 31 cases/1000 adults
• Cardinal features
• Period of 6 months with prominent tension, worry, and
feelings of apprehension about everyday problems
• Present in most situations
• Muscle tension
• Irritability
• Sleep loss
• Gastrointestinal upset
• Chronic symptoms present but usually less intense than
panic
 Treatment for GAD
Pharmacological
• Venlafaxine
• Paroxetine
• Benzodiazepines
• Buspirone
Cognitive-Behavioral
• Teaching to react differently to situations and
bodily sensations
• Awareness of thinking patterns
• Exposure to feared situations
 Panic
Disorder
 Dr. Sharon
• 31 year old physician- joined a new hospital after a
training
• Recent stress- training, moving, finding a new house,
school arrangements
• One morning was late- driving- ‘something dreadful is
going to happen’- ‘might die’- palpitation, nausea, dizzy,
SOB, - profuse sweating’  subsided
• Consulted a colleague PE, ECGNAD- ‘stress’
• Evening –fear – asked one of her colleagues to drive her
• Next 2 weeks- anx – then another attack- impossible to
drive
 PD
• Prevalence in general population 8 cases/1000
adults
Cardinal features
• Discrete episode of intense fear or discomfort with
crescendo pattern; starts abruptly and Peak in 1
minute, lasts for 5-15 minutes, sometimes 1 hour
• Occurs in many situations, with a hurried exit the
typical response
• Sense of imminent disaster or impending doom
• Shortness of breath, dizziness, diaphoresis, palpitations,
chest pains, acral paraesthesias
• Chest pain may occur- occ. Radiating to left side of neck
• Varies – daily to monthly, occasionally ‘episodic’
 Panic Disorder…
• Individual feels like they are going crazy, lose control, or die
• Unexpected or situationally triggered – social situations or
specific objects- most ‘out of the blue’
• ‘Nocturnal’ PA occur
• Anticipatory anxiety
• Hyperventilation, or rapid deep breathing, is a key symptom
• Prevalence – 0.5%
• More common in females (2:1)
• Strongly familial
• Onset – late teens or early 20’s
• ‘Fearless panic attacks (PA without panic)
• Complications- agoraphobia, substance use disorder
 Etiology
• Panicogens
– Lactate infusion, CCK, 5% CO2, flumazenil
• PET – asymmetric metabolism of
Parahippocampal gyrus
• Locus ceruleus and temporal lobes
• MVP – not causal
 Panic Disorder
• Treatments for Panic Disorder include:
– Psychotherapy
– Anti-depressant drugs
• SSRI- sertraline, paroxetine, citalopram
• TCA- nortriptyline
• Start low, go slow
– Benzodiazepine
• Clonazepam, not > 6 weeks, taper
• Others – divalproex,
– Combined treatment
• Common co-existing disorders include:
– Social phobia
– Agoraphobia.
Phobias
 PAD
• Prevalence in general population 11 cases/1000 adults
Cardinal features
– Strong and persistent fear of a specific object or situation – so
strong it interferes with daily living.
• Anxiety’s best friend
– Avoidance
– This is the key to maintaining anxiety
– Negatively reinforces through rapid reduction in anxious state
• Medically relevant phobias include
– Blood, hospitals, needles, doctors and (especially) dentists, and
painful or unpleasant procedures.
Agoraphobia
 Agoraphobia
• Severe in that most are unable to leave the house
• Life time prevalence – 1-2%
• Females more likely to have the disorder
• Onset – late adolescence, 20s or early 30s
• Prone to panic attacks, often evolves as a com/o PD
• Possible substance abuse
• Obsessive-compulsive disorders may accompany the
disorder
• More associated disorders – anxiety and depression
• Treatment
– Treat panic disorder first
– Then behaviour therapy
Social Phobia
 Social Phobia
• Life time prevalence – 2-3 %
– In Gen. Population – F>M, in Clinical M>F
– Onset typically in teenage
• Diagnosis:
– fear of scrutiny or exposure to strangers
– patient fears showing anxiety or acting in an embarrassing way
– interferes with social or job functioning
• 2 types
– Circumscribed: If alone may be accomplished
– Generalized – may become isolated and house bound despite desire for
social contact
• DD
– Specific phobia – whether alone or not
– Normal performance anxiety
 Social Phobia -
Treatment

• Cognitive-behavioral therapy
• Exposure therapy (desensitization)
• B-blocker (propanolol, atenolol)
• Benzodiazepine (alprazolam, clonazapam)
• MAOI (Nardil)
• SSRI
Specific Phobia
Specific Phobia
• marked, unreasonable fear
of specific stimulus or
situation
• stimulus avoided
• interferes with functioning
• most common (to least
common):
animals, storms, heights,
illness, injury, death
• Blood injury phobia- ‘symp’
fall by ‘parasymp’, M= F
• Treatment – CBT, modeling,
syst. desensitization
 OCD- Obsessive
Compulsive Disorder
Obsessive-Compulsive Disorder
• There are two distressing symptoms that
comprise obsessive-compulsive disorder.
– Obsessions are repetitive, unwelcome streams of
thought.
• Aggressive impulses (50%)
• Contamination (55%)
• Sexual impulses (32%)
• Need for symmetry (37%)
– Compulsions are repetitive, almost irresistible
actions.
• Obsessive thoughts generally lead to compulsive actions.
• Checking and cleaning are two very common compulsive
behaviors. – ‘touchers’, ‘arrangers’,
• St. ‘private’
 Obsessive-Compulsive Cleaners
and Checkers
Cleaners Checkers

Sex distribution Mostly females Equal

Dominant emotion Anxiety, similar to Guilt, shame

phobia
Speed of onset Usually rapid More often gradual

Life disruption Dominates life Usually do not

disrupt job and
family life
Ritual length <1 hour at a time Some go on
indefinitely
Feel better after Yes Usually not
riutals?
 OCD
• Epdemiology
– LTP 2-3% M=F
• Onset in late teens/early 20s, range from childhood to late 30s
• Most O+C, 15-20% O only, 5% C only
• Insight
– Most
– In a minority lost- ‘Psychotic OCD’
• Course- chronic, waxing and waning
• DD
– MDD/BPdepression
– Syndenham’s chorea
– Focal lesions of basal ganglia
– Post encephalitic
– SPS
– Medications (clozapine)
 Treatment
• BT – effective for compulsions, not for
obsessions (exposure, response prevention)
• Medications
– SSRI
• Fluoxetine 80mg, sertraline 200mg , fluvoxamine 300 mg,
paroxetine 60mg,
– Clomipramine 250mg
– If not fully effective, search for h/o tics- if so
haloperidol, risperidone, olanzapine
• Combined treatment
 Dissociative
Disorders

Disorders in
which there is a
prolonged loss
of memory or
identity
 Dissociative Disorders
• Dissociative Amnesia
• Dissociative Fugue
• Dissociative Identity Disorder (Multiple
Personality Disorder, MPD)
• Trans and possession disorders
• Dissociative motor disorders
• Dissociative convulsions
• others
 Conversion Disorder
• More common in females
• Prevalence figures vary between 5 – 20%
• More common in low socio economic groups
Etiology
• Psychological theories
• Neurobiological basis supported by: hypometabolism
finding in the dominant hemisphere and
hypermetabolism in the non dominant hemisphere
• In 10 - 50% of these patients, a physical disease
process will ultimately be identified
 Conversion Disorder:
Diagnostic Features
• Key Feature: Patient complains of isolated symptoms
that seem to have no physical cause, e.g., blindness,
deafness, stocking anesthesia
• Criteria
– Symptoms are preceded by stressors
– Symptoms are not intentionally feigned or produced
– No neuro, medical, substance abuse or cultural explanation
– Must cause marked distress
 Course and Treatment
• 90% resolve
• 75 %of patients have a single episode
• Spontaneous remission is often the case
• Anxiolytics helpful
• Amytal interview for obtaining information
• Insight oriented psychotherapy best
Somatoform
Disorders
 Somatoform Disorders

• Disorders in which individuals have

symptoms typically associated with
physical conditions, but for which no
physiological basis can be found
 Classification ICD-10
• Somatization disorder
• Undifferentiated somatoform disorder
• Hypochondrial disorders
• Somatoform autonomic dysfunction
– CVS, UGIT, LGIT,RS, GUT, Others
• Persistent somatoform pain disorder
Factors that Facilitate Somatization

• Gains of illness • Cultural attitudes

• Social isolation • Religious factors
• Amplification • Stigmatization of
• Symptoms used as psych illness
communication • Economic issues
• Physiologic • Symptomatic
concomitants of treatment
psych d/o
Chronic multiple functional
somatic symptoms
Somatoform
Disorder
Charles Darwin (1809-82)
suffered from chronic anxiety
and varied physical symptoms
that began shortly after his
voyage in the Beagle to South
America (1831-6). Despite
many suggested medical
explanations, these
symptoms, which disabled
him for the rest of his life and
largely confined him to his
home, remain medically
unexplained
Fat Files
 CMFS
• Evoke despair, anger, and frustration in doctors, - referred to as
"heartsink patients," "difficult patients," "fat folder patients," and
"chronic complainers."
• Over 4% of the general population and 9% of patients in tertiary
care have CMFS.
• Each primary care doctor will have on average 10-15 such
patients.
• Most patients with CMFS are women. They often have
recurrent depressive disorder and a longstanding difficulty with
personal relationships and may misuse substances.
• The risk of iatrogenic harm from over-investigation and over-
prescribing
• Potential CMFS patients may be identified simply by the
thickness of their paper notes, from records of attendance and
hospital referral, and by observation of medical, nursing, or
clerical staff.
 Assessment
• One doctor is identified - principal carer.

• Case notes – reviewed- compile a summary -

evaluate critically complaints and diagnoses-
include key investigations performed to date -
patients' personal and family circumstances.

• Long appointment - one or more - current

problems and history fully explored. - concerns,
emotional state, and social situation and the
association of these with their symptoms- agree
a current problem list
 Assessment
• Elicit a history of the current complaints- recent life events
• Find out what the patient has been told by other doctors (as
well as friends, relatives, and alternative practitioners).
• Elicit an illness history that addresses previous experience of
physical symptoms and contact with medical services (such
as illness as a child, illness of parents and its impact on
childhood development, operations, time off school and
sickness absence)
• Explore psychological and interpersonal factors in patient's
development (such as quality of parental care, early abusive
experiences, psychiatric history)
• Interview a partner or reliable informant (this may take place,
consent permitting, in the patient's presence)
• After the interview attempt a provisional formulation
 Management
• The initial long interviews - foster a positive
relationship - arrange to see the patient at
regular, though not necessarily frequent, fixed
intervals. These consultations should not be
contingent on the patient developing new
symptoms. Consultation outside these times
should be discouraged.
• Planned review
All symptoms - acknowledged as valid. - review
of symptoms enhances the doctor-patient
relationship and minimises the likelihood of
missing new disease.
 Useful Interviewing Skills
• Adopt a flexible interviewing style "I wonder if
you've thought of it like this?"
• Try to remind the patient that physical and
emotional symptoms often coexist "I'm struck by
the fact that, in addition to the fatigue, you've
also been feeling very low and cannot sleep"
• Try "reframing" the physical complaints to
indicate important temporal relationship with
relevant life events
• Respond appropriately to "emotional" cues such
as anger
 Useful Interviewing Skills…
• Explore patient's illness beliefs and worst fears
"What is your worst fear about this pain?"
• Reassurance that "nothing is wrong" may be
unhelpful, possibly because a patient's aim may
be to develop an understanding relationship with
the doctor rather than relief of symptoms.
Focused physical examination can be helpful,
but minimize diagnostic tests and referrals to
specialists. Reduce unnecessary drugs
gradually over time.
Management strategy for patients with chronic multiple
functional somatic symptoms

• Try to be proactive rather than reactive - aim to broaden

the agenda with patients - establishing a problem list and
allowing patients to discuss relevant psychosocial
problems
• Stop or reduce unnecessary drugs
• Try to minimize patients' contacts with other specialists or
practitioners
• Try to co-opt a relative as a therapeutic ally to implement
your management goals
• Reduce your expectation of cure and instead aim for
containment and damage limitation
• Encourage patients (and yourself) to think in terms of
coping and not curing
 Explanation
• Present patient's problems as a summary with an invitation to
comment:
• "So let me see if I've understood you properly: you have had a
lot of pain in your abdomen, with bloating and distension for
the past four years. You have been attending the (GP) most
weeks because you've been very worried about cancer (and
about your husband leaving you). You also told me that these
pains often occur when you are anxious and panicky, and at
these times other physical complaints such as trembling and
nausea occur.
• "I'm struck by the fact that all these complaints began soon
after you had a very frightening experience in hospital, when
your appendix was removed and you felt that `No one was
listening to my complaints or pain.'
• "Have I got that right, or is there anything I've left out?"
 Support for Doctors
• Support for doctors
General practitioners managing patients with
CMFS should arrange ongoing support for
themselves, perhaps from a partner or another
member of the primary care team with whom
they can discuss their patients. A doctor and, for
example, a practice nurse can jointly manage
some of these patients if there is an agreed
management plan and clear communication.
 Referral to Psychiatrists
• Not all doctors have the necessary skills or time - decline
in the number of "general physicians" - specialist mental
health services' increasing focus on psychotic illness
• If referral is sought two questions must be considered:
– "Are there any local and appropriate psychiatric services?" -
liaison psychiatry services if available
– "How can I prepare the patient for this referral?" - a discussion
emphasizing the distressing nature of chronic illness + expertise
of the services in this area+ a promise of continuing support
from the primary care team.
– If possible, the psychiatrist should visit the practice or medical
department and conduct a joint consultation.
 Specialist Assessment
• Before interviewing a patient, it is useful to
request both the general practice and
hospital notes and summarize the medical
history.
• Several important interviewing skills - a
technique called reattribution, which has
been developed to help the management
of patients with functional somatic
symptoms.
 Cause of CMFS
• A variety of biological, psychological, and social factors -
vary between patients
Recent developments in neuroscience show altered
functioning of the nervous system associated with
functional symptoms, making the labeling of these as
"entirely psychological" increasing inappropriate
• With our current knowledge, it is best to maintain
"aetiological neutrality" about the cause of functional
symptoms
• The main task of treatment is to identify those factors that
may be maintaining a patient's symptoms and disability
 Maintaining Factors
• Depression, anxiety, or panic disorder
• Chronic marital or family discord
• Dependent or avoidant personality traits
• Occupational stress
• Abnormal illness beliefs
• Iatrogenic factors
• Pending medicolegal claim
 Specialist Management
• First sage- shared formulation of the problems
• Plan of management negotiated.
• Adopt a collaborative approach rather than a didactic or
paternalistic manner. If it is difficult to arrive at an
understanding of why -address those factors that are
maintaining the symptoms.
• Assessment and management go hand in hand. - to modify
patients' often unrealistic expectations of the medical
profession and to remind them of the limits to medicine. -
attempt to broaden the agenda- helping patients to address
personal concerns and life problems as well as somatic
complaints. - to concentrate on coping rather than seeking a
cure.
• This process requires patience, and a capacity to tolerate
frustration and setbacks – long term benefits
Approaches
Common Problems in Management
• Firstly, preoccupation and anxious concern about
symptoms  make unhelpful demands of their doctor,
which prove difficult to resist.
• Secondly, there may be evidence of longstanding
interpersonal difficulties, as indicated by remarks such as
"Nobody cares" or "It's disgusting what doctors can do to
you." - may reflect poor quality parental care or
emotional deprivation in childhood. They are important
for two reasons:
– firstly, the doctor may take these remarks personally, become
demoralised or angry, and retaliate, which will destroy the
doctor-patient relationship;
– secondly, the attitudes revealed may require more detailed
psychological exploration.
Pain and Depression
 Pain and Depression
• Physical symptoms account for half of all
primary care visits
• Most of these are never explained by
disease or injury
• Predictors
– 6 or more physical symptoms, recent stress ..
• Often undiagnosed
– Medical training ‘ruling out’- looking for zebras
in a herd of horses
Depression in Physical Symptoms
Depression in Physical Symptoms
 Tripartite model of depression

Interest Anxiety
Appetite
Energy Aggression
Mood
motivation Impulse
Emotion
tension

Norepinephrine Serotonin
 Treatment- Challenges
• Relapse and chronicity
• Stigma- explain chemical basis
• Useful adjuncts
– Case management involving active patient
follow-up;
– Adherence monitoring;
– Symptom tracking; and
– Changing treatment if it is found unsuitable.
 Treatment- Challenges
• Only 1/3rd achieve remission
• The rest have higher risk of relapse
and recurrence
– 50% after first episode, 50-90 % after 2,
after 3 episodes  >90%
– Up to 1/3rd – chronic
 Start With SSRIs
• Good efficacy
• Dosing simplicity
• Follow the patients closely for response
• After 2 weeks – if not responding – titrate
upwards
• Confirm compliance- do not assume
• Tell about risk of relapse
• Address stress, pain, substance use
 When SSRI fail
• Switching - try another category with
mixed mechanism – dual action
• Superior pain relief
• Duloxetine
• TCAs –
– Urinary retention, arrhythmias, hypertension
• Augmenting
• ECT
Beyond the Blues- Broken Heart
• Depression – 4th leading cause of
disability- will be the second cause of
morbidity/mortality in 2020
• Cardiovascular diseases- 5th now- will be
the no. 1 cause of mortality
• Both common – many will be with both
 Broken Heart
• Risk factor for developing AMI X 4
• Mortality X 4
• HPA axis
– Increased Catecholamines - arrythmia
– Decreased HR variability
– Platelets- increased activation in depression
• Inflammation
– Increase in factors of subacute inflammation
• Treatment
– SSRI protective effect (citalopram / sertraline)
Factitious Disorder
 Factitious Disorder
• Key Feature: Physical or psychological
symptoms are intentionally produced to
assume sick role
• External incentives are absent-
voluntary production of symptoms
• Types
– Factitious Disorder
– Factitious Disorder by Proxy
 Factitious Diseases and
Malingering
• Direct evidence needed
• Most patients with factitious disorders are women with stable
social networks
• More than half of these work in medically related occupations.
• Confront the patient but remain supportive. - organise a
multidisciplinary meeting involving the patient's general
practitioner, a physician and surgeon, a psychiatrist, and a
medicolegal representative.
• only if, feigning can be established should patients be
confronted- psychiatrist and the referring doctor - can carry
out the confrontation jointly. This "supportive confrontation"
• After confrontation, patients usually stop the behaviour or
leave the clinic. Only sometimes do they engage in the
psychiatric care offered.
 Factitious Disorder
• Key Feature: Physical or psychological
symptoms are intentionally produced to assume
sick role; conscious/voluntary symptom
production
• Types
– Factitious Disorder
– Factitious Disorder by Proxy
• Münchausen's syndrome – the patient, who is often a
man with sociopathic traits and an itinerant lifestyle, has
a long career of attending multiple hospitals with
factitious symptoms and signs
 Malingering
Distinction.
– Malingerers deliberately feign symptoms to
achieve a goal (such as to avoid
imprisonment or gain money).
– Malingering is behaviour and not a diagnosis.
The extent to which a doctor feels it
necessary to confront this issue will depend
on the individual circumstances.
Somatization Disorder
 Somatization Disorder

• Prevalence = 0.5%

• 5 times more common in women

• Usually starts before age 30

• Comorbidity high for other mental disorders

(paranoid, avoidant, dependant and obsessive-
compulsive personality disorders)
 Somatization Disorder:
Diagnostic Features
• Key feature: Multiple, unexplained
symptoms
• Criteria
– Four pain symptoms, plus
– Two GI symptoms, plus
– One sexual/reproductive symptom, plus
– One pseudoneurological symptom
– If within a medical condition, excessive symptoms
– Lab abnormalities absent
– Cannot be intentionally feigned or produced
 Somatization Disorder:
Associated Features
• Colorful, exaggerated terms
• Inconsistent historians
• Depressed mood and anxiety symptoms
• Rarer in men
• Chronic, rarely remits completely
• Lifetime prevalence: 0.2% - 2% F
< 0.2% among men
 Differential Diagnosis

• Medical illnesses which have multiple

symptoms (Multiple sclerosis, SLE,
Myasthenia, AIDS, hyperthyroidism and
hyperparathyroidism, acute intermittent
porphyria, chronic infections
• Psychiatric illnesses (depression,
factitious, generalized anxiety disorder,
hypochondriasis)
Hypochondriasis
 Hypochondriasis
• Preoccupation with the fear of
contracting an illness (HIV
hypochondriasis)
Or
• Preoccupation with the belief of having a
serious illness
 Hypochondriasis:
Diagnostic Features
• Key feature: Excessive preoccupation with
fear of disease or strong belief in having
disease due to false interpretation of a
trivial symptom
• Criteria
– Unwarranted fear or idea persists despite reassurance
– Clinically significant distress
– Not restricted to appearance
– Not of delusional intensity
 Hypochondriasis:
Associated Features
• Medical history often presented in great detail
• Doctor-shopping common
• Patient may believe s/he is not receiving proper
care
• Patient may receive cursory PE; med condition
may be missed
• Negative lab/physical exam results
• M=F
• Primary care prevalence: 4 - 9%
• May become a complete invalid
 Etiology
• Patients have low tolerance for stress
• Low thresholds for pain or discomfort
• Sick role theory
• High comorbidity for depression and
anxiety (over 80%)
 Differential Diagnosis

• Somatization disorder difficult but

distinguished on the basis of concern by
this patient about symptoms rather than a
disease. Also hyponchondriacs tend to
have fewer symptoms
Body Dysmorphic Disorder
 Body Dysmorphic Disorder
• Preoccupation with an imagined defect
• Onset between ages 15 – 20
• Women more affected
• Associated with obsessive compulsive
personality
• Most common site is hair followed by nose
 Course and Treatment

• Chronic if untreated

• Physical treatment is usually unsuccessful

• SSRI and clomipramine useful

Somatoform Pain Disorder
 Pain Disorder
• Clinical significant complaints of pain

• Associated psychological factors related to

the onset, severity, exacerbation and
maintenance of the pain
 Epidemiology
• Low back pain affects about 7 million
people in the USA
• Peak age of onset in the 40’s
• Twice as common in females
• More common in lower socio economic
groups
 Treatment
• Insight oriented and supportive
psychotherapy
• SSRI’s
• Biofeedback
• Anxiolytics should be used cautiously
Undifferentiated Somatoform
Disorder
 Undifferentiated Somatoform
Disorder

• One or more physical complaints that last

for six months but not as extensive as the
somatization disorder
Acute Stress
Disorder
 Acute Stress Disorder
• Like PTSD, except symptoms last less
than one month and begin within one
month of the traumatic event
• dissociation symptoms (numbing, dazed,
derealization, depersonalization, amnesia)
• reexperience the trauma
• avoidance
• hyperarousal
PTSD
 Posttraumatic Stress Disorder
(PTSD) - Diagnosis
• Symptoms present more than one month
• Exposure to a traumatic event that caused
intense fear, helplessness, or horror
• Reexperience the event (flashbacks, night-
mares, distress when reminded of event)
• Avoidance/numbing (amnesia, intentional
forgetting, detachment, anhedonia)
• Hyperarousal (insomnia, irritable,
hypervigilant, startles easily)
 PTSD - Treatment
• Psychotherapy (cognitive-behavioral)
• EMDR (Eye-Movement Desensitization
and Reprocessing)
• Depression: SSRI, TCA
• Hyperarousal: clonidine, propanolol
• impulsivity/mood lability: valproic acid
• Avoid benzodiazepines