NEUROSIS

INRODUCTION:

The term neurosis encompasses a variety of very common mental health disorders that were once classified as a neurosis are now more accurately categorized as neurotic disorders. The term “Neurosis” was coined by the Scottish doctor William Cullen in 1769 to refer to "disorders of sense and motion”. It derives from the Greek word neuron (nerve) with the suffix -osis (diseased or abnormal condition). In ICD-10 the neurotic disorders are classified under, ‘neurotic, stress related and somatoform disorders’ from F40-F48.

DEFINITION:

Neurosis is defined as a mild to moderately severe illness of the personality, in which the ego function of reality testing is not gravely affected and maladjustment to life is limited.

Neurosis is a functional mental disorder characterised by high level of anxiety and other distressing emotional symptoms such as fears, obsessive thoughts, compulsive acts, somatic reactions, dissociative states and depressive reactions. The symptoms do not involve gross personality disorganisation, total lack of insight or loss of contact with reality. –Longman Dictionary of Psychology and Psychiatry.

The term neurosis is defined as: The presence of a symptom or group of symptoms which cause subjective

distress to the patient. The symptom is recognised as undesirable (i.e. insight is present). The personality and behaviour are relatively preserved and not grossly

disturbed. The contact with reality is preserved. There is an absence of organic causative factors.

CAUSES OR ETIOLOGY OF NEUROSIS:

1. Biological Factors: Inherited predisposition has a little role to play. But biological and psychological factors together may precipitate neurosis. For example, a hypersensitive person with family background in which attention is given to very small things will have anxiety in everyday life. So an anxious environment at home by parents or other family members may contribute to neurosis.

2. Psychological Factors: In neurosis maladaptive learning, use of anxiety defences, blocked personal growth, pathogenic inter-personal relationship, stress and decompensation play an important role.

Maladaptive learning - This is when an individual is not able to learn the correct or proper adaptive technique to solve the problem of life. For eg., a person who has not

prepared well for examination avoids it by telling her parents that she is feeling very sick or having abdominal pain. Such an individual is not able to achieve a level of maturity and fails to learn competencies.

Anxiety defence : This is introduced as a causative factor by Freud. He described that threatening inner desires and impulses produce anxiety in a person, to overcome them the person uses ego defence mechanisms such as denial, repression and undoing ect. He may use them repeatedly and lead to neurosis.

Blocked personal growth : personal growth may be blocked due to various factors. It may be that a person does not get needed opportunities. For example environmental factors such as values of society may not let the girl, go out and work. Then there is faulty socialisation where the thinking is towards factors of satisfying the basic needs. This gives a feeling of inadequacy to a person when he/she is exposed to an environment which is demanding.

Pathogenic interpersonal patterns : Pathogenic interpersonal patterns in the family develops a feeling of inadequacy and despair in an individual.

Stress and decompensation : Various types of stressors cause a lot of pressure on an individual, especially where the chance of compensating is less.

3. Sociocultural factors: Sociocultural factors also play an important role in development of neurotic disorders.Conversion hysteria is common in low socio-economic status people with less education, while anxiety and obsessive compulsive neurosis are common in upper socio-economic status people.

CLASSIFICATION OF NEUROSIS

NEUROSIS

Anxiety Phobias Obsessive Neurotic Neuras- Deperso- Hypochon- PTSD Compulsive Depression thenia nalisation driasis Hysteria Neurosis (OCN)

Conversion Dissociative Reaction reaction

Dissociative amnesia Multiple personality Dissociative Somnambulism Fugue

NEUROTIC DISORDERS:

NEUROSIS

1. ANXIETY DISORDER: Anxiety is the commonest psychiatric symptom in clinical practice and anxiety disorders are one of the commonest psychiatric disorders in general population.Freud first introduced the term anxiety neurosis in 1895. Anxiety is a normal phenomenon which is characterised by a state of apprehension or unease arising out of anticipation of danger. Anxiety is often differentiated from fear, as fear is an apprehension in response to an external danger while in anxiety the danger is largely unknown.

DEFINITION:

An emotional response (e.g., apprehension, tension, uneasiness) to anticipation of danger, the source of which is largely unknown or unrecognised. Anxiety may be regarded as pathological when it interferes with effectiveness in living, achievement of desired goals or satisfaction, or emotional comfort. (Shahrokh & Hales,2003).

Ross has defined it, as a series of symptoms, which arise from faulty adaptation to the stresses and strain of life. It is caused by over action in an attempt to meet these difficulties.

HOW MUCH IS TOO MUCH?Anxiety is usually considered a normal reaction to a realistic danger or threat to biological integrity or self-concept. Anxiety can be considered abnormal or pathological if:

It is out of the proportion to the situation that is creating it. The anxiety interferes with social, occupational, or other important areas of

functioning. ETIOLOGY:

i. Psychodynamic theory: Anxiety is basically due to a conflict, a conflict between ID and Superego where ego is not able to meditate effectively. Failure to this anxiety occurs. For various reasons like unsatisfactory parent-child relationship causes delayed ego development. Overuse or ineffective use of ego defence mechanisms results in maladaptive Reponses to anxiety.

ii. Emotional conflict: According to McDougall and Gardon, the anxiety neurosis can arise as a result of conflicts between two emotions.

iii. Repression of the self-assertive tendency: According to Adler, man's most important and most intense impulse is to assert himself. If the persons ego does not develop properly and he instead develops a sense of inferiority then his self-assertive is repressed, and this leads to development of an anxiety neurosis.

iv. Biological theory:

Genetic evidence - About 15-20% of first degree relatives of the patients with anxiety disorder exhibit anxiety disorders themselves.

Chemically induced anxiety states - Infusion of chemicals like sodium lactate, isoproterenol and caffeine and inhalation of 5% CO2 can produce panic episodes in predisposed individuals.

GABA-benzodiazepine receptors - This is one of the most recent advances in search for the aetiology of anxiety disorders. GABA(gamma amino butyric acid) is the most prevalent inhibitory neurotransmitter in the CNS. It has been suggested that an alteration in GABA levels may lead to production of clinical anxiety.

Other neurotransmitters - Norepinephrine, dopamine and neuroendocrine have also been implicated in the causation of anxiety disorder.

Neuroanatomical basis : Modern theory on the physiology of emotional states places the key in the lower brain centres including thalamus, hypothalamus, and the reticular formation.

Medical conditions : the following medical conditions have been associated to a greater degree with individuals who suffer anxiety disorder than in general population:

Abnormalities in the hypothalamic-pituitary-adrenal axis. Coronary artery disease, MI Pheochromocytomas Substance intoxication and withdrawal Hypoglycaemia Caffeine intoxication

SYMPTOMS OF ANXIETY:1. PHYSICAL SYMPTOMS

a) Motoric symptoms: Tremors, restlessness, muscle twitches, fearful facial expressionb) Autonomic and visceral symptoms : Palpitations, tachycardia, sweating flushes, dysponea, hyperventilation, dry

mouth, dizziness, diarrhoea ,pupil dilation, frequency of micturation.2. PSYCHOLOGICAL SYMPTOMS

a) Cognitive symptoms :-Poor concentration, distractibility, hyper arousal, negative automatic thoughts.

b) Perceptual symptoms:- Derealisation, depersonalisation.c) Affective symptoms:- Diffuse, unpleasant and vague sense of apprehension,

fearfulness, inability to relax, irritability, fear of losing control and dying.d) Other symptoms: Insomnia, increased sensitivity to noise, exaggerated startle

response.

TYPES OF ANXIETY DISODER:

1. GENERALIZED ANXIETY DISODER-Generalized anxiety disorder is characterised by chronic, insidious onset with unrealistic and excessive anxiety and worry which may or may not be punctuated by repeated panic attacks. The symptoms of anxiety should last for at least a period of 6months or long and should not be associated with organic factors for a diagnosis to be made.

2. PANIC ANXIETY DISORDER-This is characterised by discrete episodes of acute anxiety. The episode is usually sudden in onset, lasts for a few minutes and is characterised by severe anxiety. Classically the symptoms begin unexpectedly or ‘out of the blue’. Usually there are no apparent precipitating factors, though some patients report exposure to phobic stimuli as a precipitant.

TREATMENT The treatment of anxiety disorder is usually multi modal.

1. Psychotherapy: Psychoanalytical therapy is not usually indicated, unless personality problem coexist. Usually supportive psychotherapy is used either alone, when anxiety is mild, or in combination with drug therapy. The establishment of a good therapist-patient relationship is often first step in psychotherapy. Recently, there has been increasing use of CBT in the management of anxiety disorders. It works to restructure your thinking patterns and behaviours which trigger your attacks.

2. Relaxation techniques: In patients with mild to moderate anxiety relaxation technique is very useful. These techniques are used by the patients himself as a routine exercise every day and also whenever anxiety provoking situation is at hand. The techniques include- yoga, pranayama , self hypnosis and meditation.

3. Exposure Therapy - This type of therapy is used to expose patients to the physical sensations of panic in a safe environment. It forces you to feel the feelings of anxiety and panic and works to teach your healthier ways of coping with these feelings.

4. Drug treatment: The drugs of choice for generalised anxiety disorder are benzodiazepines, and for panic disorder antidepressants. Benzodiazepines (like alprazolam and clonazepam) are useful in the treatment of anxiety disorders.

OBSESSIVE COMPULSIVE DISORDER

Obsessive-Compulsive Disorder (OCD) is an anxiety disorder where a person has recurrent and unwanted ideas or impulses (called obsessions) and an urge or compulsion to do something to relieve the discomfort caused by the obsession. The obsessive thoughts range from the idea of losing control, to themes surrounding religion or keeping things or parts of one's body clean all the time. Compulsions are behaviours that help reduce the anxiety surrounding the obsessions. Most people (90%) who have OCD have both obsessions and compulsions. The thoughts and behaviours of a person with OCD are senseless, repetitive, distressing, and sometimes harmful, but they are also difficult to overcome.

DEFINITION-An obsession is defined as:

An idea, impulse or image which intrudes into the conscious awareness repeatedly. It is recognised as one’s own idea, impulse but is perceived as egoalien ( foreign to

one’s personality. It is recognised as irrational and absurd i.e insight is present. Patient tries to resist against it but is unable to. Failure to resist, leads to marked distress. An obsession is usually associated with compulsion.

A compulsion is defined as: A form of behaviour which usually follows obsessions. It is aimed at either preventing or neutralizing the distress or fear arising out of

obsession. The behaviour is not realistic and is either irrational or excessive. Insight is present, so the patient realizes the irrationality of compulsion. The behaviour is performed with a sense of subjective compulsion. Compulsion

temporarily diminishes the anxiety associated with obsessions. ETIOLOGY

i. Psychoanalytical theory: psychoanalytical theorists propose that individual with OCD have weak, underdeveloped egos for variety of reasons: unsatisfactory parent-child relationship,conditional love. The psychoanalytical concept views clients with OCD as having regressed to earlier developmental stages. Regression to the earlier stages combined with use of specific ego defence mechanism like isolation, undoing, displacement, reaction formation produces the clinical symptoms of OCD.

ii. Biological Theories:There is an increased genetic predisposition in first degree relatives (5-7%) and greater concordance between monozygotic as compared to dizygotic twins. However the types of obsessive and compulsive are not always the same in different affected family members. There is also genetic association between

Tourette’s syndrome, chronic motor tic disorder and OCD. Indeed, up to 20 percent of individuals with OCD may have tics, which in turn are suggestive of basal ganglia disorder. There is also an increased incidence of OCD in those who have suffered brain

injury, for example due to head injuries, encephalitis or syphilis. Evidence for a

neurobiological basis has been accrued from positron emission tomography (PET)

and magnetic resonance imaging (MRI) techniques, in which orbitofrontal and

cingulated cortices and basal ganglia abnormalities have been found, as have

reductions bilaterally in the size of the caudate nuclei and retrocallosal white

matter. These findings all suggest structural abnormalities in the brain in at least

some cases of OCD.

There is also evidence for abnormalities in serotonin (5-HT) transmission in the

central nervous system. Some children and adolescents develop OCD after β-

haemolytic streptococcal infections, suggesting an autoimmune etiology. However,

at present moment, there is no conclusive evidence for OCD having clearly proven

organic etiology.

iii. Behavioral Theory:-The behavioural theory explains obsession as condition stimuli

to anxiety that is similar to phobias. While compulsions have been described as

learned behavior which decrease the anxiety associated with obsessions. This decrease

in anxiety positively reinforces the compulsive acts and they become ‘stable’ learned

behaviors.

Clinical Syndrome

ICD-10 classifies OCD into three clinical subtypes which are :

1. Predominantly obsessive thought or ruminations,

2. Predominantly compulsive acts (compulsive rituals), and

3. Mixed obsessional thoughts and acts

Depression is very commonly associated with OCD. It is estimated at least half the

patient of OCD have major depressive episodes while many other have mild depression.

There are several clinical syndromes have been described in literature, although admixtures

are commoner than pure syndromes. Those major clinical syndromes are:

i. Washers (contamination)--This is the most common type. Here the obsession is of

contamination with dirt, germs, body excretions and the like. The compulsion is

washing of hands or the whole body, repeatedly many times a day. It usually spreads

onto washing of clothes, bathroom, bedroom, door knobs and personal articles,

gradually. The person tries to avoid contamination but unable to, so washing becomes

a ritual.

ii. Checkers (doubt)--In this type the person has multiple doubts, for example the door

has not been locked, kitchen gas has been left open, counting of money was not exact

and etc. the compulsion, of course, is checking repeatedly to remove the doubt. Any

attempts to stop the checking leads to mounting anxiety before one doubt has been

cleared, other doubts may creep in.

iii. Pure obsession (intrusive thought)--This syndrome is characterized by repetitive

intrusive thoughts, impulses or images which are not associated with compulsive acts.

The content is usually sexual or aggressive in nature. The distress associated with

these obsessions is dealt usually by counter-thought for example praying, “undoing”

actions, asking for reassurance and counting but not with rituals.

iv. Primary obsessive slowness (symmetry)--It is characterized by several obsessive

ideas and or extensive compulsive rituals, in the relative absence of manifested

anxiety. This leads to marked slowness in daily activity. Usually the person demand

on being need for symmetry and precise arranging so in order to neutralize it they will

continue Ordering, arranging, balancing, straightening until "just right" or perfect in

their eyes.

v. Hoarders: Hoarders collect insignificant items and have difficulty throwing away

things most people would consider to be of no value. Hoarders often have chaotic

living environments as a result of their extensive collections.

SYMPTOMS AND SIGNS OF OCD

Aggressive obsessions

Contamination obsessions

Sexual obsessions

Hoarding/saving obsessions

Religious obsessions

Obsessions with need for symmetry or exactness

Miscellaneous obsessions

Cleaning/washing compulsions

Checking compulsions

Repeating rituals, counting compulsions.

Ordering/arranging compulsions

Collecting compulsion

Miscellaneous compulsions.

Treatment

1. Psychotherapy

There are two types of psychotherapy that can be done to OCD patient. The first one is

the psychoanalytic psychotherapy. This type of psychotherapy is used in certain patients who

are psychologically oriented especially those with anankastic personality. Secondly, is the

supportive psychotherapy which is an important adjunct to other modes of treatment.

Supportive psychotherapy is also needed by the family members.

2. Behavior and Cognitive Behavioral Therapy:-Behavior modification is an effective

mode of therapy with a success rate as high as 80% especially for the compulsive acts.

It is customary these days to combine the cognitive behavioral therapy with behavior

therapy. This involves graded self exposure and self imposed response prevention of

‘undoing’ of obsession through compulsions, and / or cognitive therapy. The techniques

that often used are thought stopping, response prevention, systematic desensitization

and modeling.

3. Drug Treatments

i. Benzodiazepines

For example alprazolam and clonazepam, but they have limited role in controlling anxiety as

adjuncts and should be used very sparingly.

ii. Antidepressant

Some patients may improve dramatically with specific serotonin reuptake inhibitors (SSRi)

Clomipramine (75-300mg/day), non specific serotonin reuptake inhibitors (SRI),

was the first drug used effectively in the treatment of OCD. The response is better in

the presence of depressive symptoms, but many patients with pure OCD also

improve substantially.

Fluoxetine (20-80mg/day), is a good alternative to clomipramine and often

preferred these days for its better side effects profile.

Fluvoxamine (50-200mg/day), marketed as specific anti-obsessional SSRI drug,

while paroxetine (20-40mg/day), and setraline (50-200mg/day) are also effective in

some patients.

iii. Antipsychotics

These are occasionally used in low doses in the treatment of severe, disabling anxiety. Some

example are haloperidol, risperidone, olanzepine, aripiprazole and pimazole.

iv. Buspirone

Has also been used beneficially as adjuncts for augmentation of SSRI, in some patient.

4. Electroconvulsive Therapy (ECT)

In the presence of severe depression with OCD, ECT may be needed. ECT is

particularly indicated when there is a risk of suicide and/or when there is a poor response to

the other modes of treatment. However ECT is not the treatment of first choice in OCD.

5. Psychosurgery

In severe, intractable, chronic and incapacitating cases, where all other treatments have

failed, streotactic site specific brain surgery has been reported to be successful. This has

included the used of radioactive yttrium implants and more recently, non invasive proton,

electron and X-ray techniques. Anterior cigulotomy, capsulotomy and limbic leucotomy

have also been found to be effective in 25-30 percent of such cases. All involve the

separation of the frontal cortex from deep limbic structures. Sadly, psychosurgery only

available as a treatment choice at a very few centers’ throughout the world.