Psychiatry: A Course of Lectures - V. S. Bitensky 2004

Neurotic, stress-related and somatoform disorders

Psychogenic Disorders (caused exclusively by information-related factors) have traditionally been classified into neuroses and reactive psychoses. This division persists to some extent even today. However, the systematization of these disorders seems to have lost its familiar logic: anything characterized primarily by affective and paranoid syndromes has been shifted to the third and second categories of ICD-10, respectively, and an entirely new fifth category has emerged to encompass certain typically neurotic states. Meanwhile, the actual "neurotic" (fourth) category of ICD-10 includes both pre-psychotic conditions and typical psychoses, such as reactive psychoses (e.g., psychogenic stupor). We will discuss this in more detail below.

As for Etiology, it raises virtually no additional questions, as we are dealing with disorders triggered by stress or chronic psychological trauma. What is surprising, however, is that the symptom spectrum hardly differs from that of hereditary endogenous organic mental disorders or those of clearly exogenous origin. This can only be explained by the immense significance (nutritive and life-sustaining) that information holds for the human Brain, placing it on a par with pathogenic factors of any other nature.

W. Cullen introduced the term "neurosis" into medical practice back in the 18th century, but it acquired its modern, specific meaning only in the late 19th century thanks to the works of J. Charcot, P. Janet, and P. Dubois. Prior to the adoption of the 10th revision of the International Classification of Diseases into the daily practice of psychiatrists, domestic psychiatry divided neuroses into hysterical, obsessive-compulsive, and neurasthenia. The previous 9th revision already featured anxiety neurosis, hysterical neurosis, two variants of obsessive-compulsive neurosis (phobic and obsessive), depressive neurosis (neurotic depression), neurasthenia, depersonalization syndrome, and hypochondriacal neurosis. Nevertheless, The Doctrine of "three core forms" developed within domestic psychiatry was quite successful, as all other neurotic disorders can, to some extent, be viewed as derivatives of hysteria, neurasthenia, or obsessive-compulsive neurosis.

Neurosis is understood as a condition that, firstly, arises as an individual's reaction to psychological trauma (which in some cases may be acute, but most often has a prolonged impact on existence); secondly, the patient's distressing experiences are always psychologically comprehensible and reflect the content of the psychotraumatic circumstances; and thirdly, the disorder gradually loses its clinical distinctiveness once the psychotraumatic factors are removed or lose their relevance for the person. This triad of symptoms is known as Jasper's triad, highlighting THE CONTRIBUTION OF the German psychiatrist Karl Jaspers to The Development of the core principles of classical psychiatry.

Thus, while psychogenic disorders like neuroses can be considered reversible, one must always keep in mind that they tend to have a protracted course and frequent symptom relapses. In addition, the symptoms frequently change ("mimic"), leading to difficulties in classifying this disorder.

In the current 10th revision, the Clinical forms of these disorders are, firstly, much more numerous than in previous ones, and secondly, neurotic, stress-related, and somatoform disorders are grouped under a single heading due to their historical connection to METABOLISM/2.html">THE CONCEPT OF neurosis and the likely association of the majority of these disorders with information-related causes.

The operational elements of neurosis include psychotraumatic circumstances, the individual and their specific traits (under identical circumstances, neuroses are more likely to develop in individuals with psychopathic personality traits), and the presence of a pathologically altered Background (a history of HEAD trauma, exhaustive work, asthenia following a past illness, or smoking).

Let us now examine the specific forms that comprise this category of neurotic, stress-related, and somatoform disorders.

Anxiety and Phobic Disorders

This group includes disorders in which anxiety is triggered exclusively (or predominantly) by specific situations and external objects that are not currently dangerous to the individual. Naturally, the patient tries to avoid them, and if avoidance is impossible, endures them with a sense of dread. The severity of anxiety can range from mild discomfort to sheer terror. Patients frequently focus on isolated symptoms, such as palpitations or dizziness-like states. Secondary fears of dying, going mad, or, at the very least, losing self-control often emerge. Anxiety also arises merely at the thought of such a situation. This disorder is more frequently observed in women. It is divided into agoraphobia, social phobias, and specific phobias.

Agoraphobia is the fear not only of open spaces or crowds, but also the dread of being unable to immediately return to a safe place—which for most people is their own home. It also includes the inability to travel alone in transport or elevators, and the fear of falling on the street and being left without help. In other words, the defining feature of agoraphobia is the lack of immediate access to an exit. The course is most often chronic, and the disorder severely disables the person, who may remain "chained" to their home for years. It is more common in women.

Social phobia is the fear of being the center of attention in a relatively small group of people, occurring with equal frequency in women and men, predominantly among young adults. It leads to the avoidance of situations such as public speaking, answering a lecturer's question in front of a group, standing up for one's interests or responding to insults in public places, and engaging in conversation within an unfamiliar circle. Characteristically, patients view their main problem in terms of secondary vegetative symptoms—blushing, hand tremors, and excessive sweating. They avoid public situations, which subsequently lowers their self-esteem.

Specific (isolated) phobias are restricted to specific situations (claustrophobia—fear of enclosed spaces, acrophobia—fear of heights, mysophobia—fear of contamination, aichmophobia—fear of sharp objects, etc.).

The names of isolated phobias are of Greek origin, and there are over three hundred of them. They typically begin in childhood and persist throughout a person's life. While agoraphobia may feature fluctuations in symptom severity across different life periods up to temporary remission, the fear of specific objects remains stable in isolated phobias. Fear of Blood and bodily injury differs from others by the onset of bradycardia (instead of tachycardia seen in other cases).

Panic Disorder

This condition also belongs to anxiety disorders. Anxiety is the leading manifestation of the illness and is not tied to a specific situation. The core feature of panic disorder is completely unpredictable attacks of severe anxiety (panic) in A wide variety of circumstances that pose no threat to life or health. Such attacks are accompanied by a range of vegetative symptoms, which are the first to be recognized by the patient and prompt them to seek medical help. These include palpitations, chest pain, a feeling of suffocation, dizziness, and an inability to concentrate or act purposefully. Derealization and depersonalization are frequently observed. Patients describe their state as if they have lost control and are forced to run and save themselves; the fear of dying is very intense, and there may also be a fear of going mad or losing control over the situation. An attack lasts up to 10 minutes. In some patients, attacks occur rarely—a few times in a lifetime—but for the majority, their frequency and intensity increase.

In its clinical manifestations, panic disorder resembles a state of caffeine intoxication, suggesting that similar pathogenetic mechanisms are involved in both cases. Comorbidity with agoraphobia has been noted (up to 70%). As for alcohol, patients often use it in an attempt to avoid recurrent panic attacks, which quickly leads to ethanol dependence. Anticipatory anxiety is typical between attacks. Having abruptly left a place where anxiety occurred (e.g., a bus), patients subsequently avoid similar situations. They appear in public places only when accompanied by a "trusted person" and very often become disabled.

Another condition is generalized anxiety disorder, whose primary manifestation is generalized, persistent, and "unfixed" anxiety arising under unfavorable microsocial conditions. It exerts a deprivating effect on the personality and can induce a state of frustration (helplessness, lack of a clear Vision for resolving a conflict situation). In terms of subjective experiences, the most frequent is the fear or anticipation that something terrible will happen to a relative. Patients experience constant nervousness, tremors, sweating, palpitations, dizziness, Muscle tension, and epigastric discomfort. This disorder is more common in women and is associated with chronic stress.

There is also mixed anxiety and depressive disorder, where it is difficult to determine whether anxiety or depression is the dominant symptom, and the severity of depression is insufficient to qualify the disorder as affective. Such patients most often receive help from general practitioners; they are typically postmenopausal women.

Obsessive-Compulsive Disorder

The main manifestation of this group of disorders is stereotypically recurring obsessive thoughts. These ideas are extremely distressing to the individual due to their aggressive nature (for instance, the patient is terrified of suddenly beating their beloved dog, while simultaneously knowing they could never cause suffering to their loyal friend or any animal whatsoever) or their absurdness (the patient is unable to change a prematurely soiled shirt because they only do so on Mondays and Thursdays). However, they can also take the form of absurd images (bloody car accident victims) or impulses (such as picking one's Nose or twisting Hair around a finger in the presence of others). It must be emphasized that neither these images, impulses, nor ideas are accompanied by a sense of being imposed from the outside by some magical force, nor by the conviction that the patient is being controlled by someone else (such a symptom is characteristic of obsessions within The Structure of a schizophrenic process).

Another typical manifestation of the disorder is compulsive actions (i.e., involving a conflict of motives) or rituals, which are no less burdensome to everyday existence than obsessive thoughts. They are unrelated to the satisfaction of functionally useful tasks (e.g., the need to wash one's hands multiple times a day without real necessity, to iron shirts first, then underwear, and trousers only at the end, or to let a vehicle pass and wait for the next one if its number starts with an odd digit, etc.). Rituals are aimed at preventing unlikely events that could harm the patient or those around them (including harm caused by the patient themselves). Generally speaking, ritualistic thinking is a rudimentary component of the human mentality as a whole; it was widely utilized during the formative stages of humanity as a thinking, social creature, when underdeveloped algorithmic approaches to Processing environmental information and ignorance of the causes of many phenomena were compensated for by The activity of such a rudimentary psychological function as belief. Religious beliefs or anniversaries of prominent events are nothing other than manifestations of ritualistic thinking. Honoring jubilee celebrants is a ritual that everyone submissively follows, without realizing that people thereby emphasize their desire to protect the life of a person who has already reached a certain age from potential future misfortunes and fatal accidents. Therefore, it is sometimes difficult to determine whether a particular ritual in a patient is a manifestation of a mental disorder or part of that collective unconscious (in C. Jung's terms) which they carry within themselves as part of a specific ethno-socio-cultural stratum. Besides rituals, compulsive actions also include slowness and indecisiveness. Researchers have noted a positive correlation between obsessions and depressions, which has led to attempts to treat obsessive states with antidepressants (Cipralex, Paxil, Fevarin, Remeron, or the earlier-generation antidepressant Anafranil). Sometimes this approach succeeds in relieving the patient of the suffering associated with obsessions. This disorder is more frequently observed in individuals with anankastic traits, is independent of gender, and begins in youth or early adulthood. Its course is chronic. Compulsive ritualistic actions respond better to behavioral therapy than obsessive thoughts, but unfortunately, both manifestations usually coexist in the same patient.

Given the great importance of obsessive-compulsive disorder for future general practitioners, let us outline its criteria according to ICD-10:

1. Obsessive-compulsive symptoms must be recognized as the individual's own thoughts or impulses.

2. There must be at least one thought or act that is still unsuccessfully resisted, even if others are no longer resisted.

3. The thought of performing a compulsive action should not inherently be pleasant for the patient. At the same time, There is a noticeable reduction in anxiety or tension following the ritual.

4. Obsessive thoughts, images, or actions recur, disrupting the individual's effort to rid themselves of this unpleasant "accompaniment".

5. Ultimately, there must be an impairment in the individual's social functioning, with the obsessive-compulsive disorders themselves acting as a source of distress.

We will not dwell on neurasthenia separately. It is worth noting that today's view of neurasthenia differs significantly from the one that dominated among previous generations of psychiatrists: most now consider neurasthenia not as a distinct psychogenic disorder, but rather as one of the manifestations of the asthenic syndrome associated with a low-symptom (latent) organic brain lesion.

Childhood neuroses are typically characterized by a predominance of fears, somatovegetative symptoms (enuresis, habitual vomiting), and motor disorders (tics, logoneurosis, hysterical paralysis). The younger the child, the more uniform the neurotic clinical picture.

Treatment of Neuroses

In the treatment of neuroses, preference is given to psychotherapeutic Methods aimed at de-actualizing or eliminating the stressor that caused the disorder for the patient. Psychotherapy methods are diverse. For example, the technique of psychosynthesis allows for The formation of a new, stress-resistant personality, concentrating it around a new "core". If a woman undergoes a Hysterectomy and this leads to a severe neurotic disorder, the therapist seeks to find those hidden qualities and interests within her soul that will subsequently determine the leading motivation, for which the consequences of the surgery will no longer be of significant importance (e.g., reorienting the patient toward educational work with "difficult" teenagers or a passion for modern cinema, etc.). Positivist techniques are aimed at ensuring that internal or external conflicts are not perceived by the patient as destructive, but rather acquire the traits of a "driver" for progressive development. The task of the psychodynamic approach (based on classical psychoanalysis) is, on the one hand, to uncover those experiences hidden deep in the patient's subconscious that led to the neurosis, and on the other hand, to provide an opportunity for abreaction, i.e., to induce catharsis. If anxiety dominates the clinical picture, anti-anxiety medications are recommended—most commonly benzodiazepines (diazepam, chlordiazepoxide, xanax, or phenazepam), other groups of tranquilizers (meprobamate), or herbal remedies (persen, deprim). Physiotherapy Procedures are used in combination with other treatment methods only as an adjunctive measure.

Reaction to Severe Stress and Adjustment Disorders

The main distinguishing feature of this group of disorders is the presence of a clear cause: an exceptionally intense traumatic life event or a chronic psychotraumatic situation (even of minor intensity). Individual sensitivity to stress in general and the personal Significance of the specific event for the subject are of paramount importance. As in the case of exogenous-organic mental disorders, the specific form of mental impairment is determined by both the specific cause and the timeframe between the action of the stressor and the reaction to it, and, most importantly, the patient's individuality. Acute stress reaction, post-traumatic stress disorder, and adjustment disorder are distinguished.

Acute stress reaction is characterized by its short duration—up to 3 days following exposure to an extraordinary stressor (such as the death of a loved one). The clinical picture is heterogeneous and can change even over such a short period. Initially, a state of peculiar "stupor" is observed (compare with losses of consciousness in acute organic brain lesions) with impaired orientation in space and, especially, in time, significant impairment of attention, inability to concentrate, and loss of the capacity for critically adequate comprehension of ongoing events. The field of consciousness is most often somewhat narrowed. Vegetative symptoms may be present, similar to those seen in panic anxiety. Amnesia regarding the traumatic episode is partial.

The clinical picture of post-traumatic stress disorder includes episodes of reliving the trauma in the form of intrusive flashbacks, dreams, or nightmares, occurring against a background of a chronic sense of "numbness" and emotional blunting, alienation, and anhedonia. Patients avoid situations that might remind them of the ordeal. If anything suddenly triggers a reminder of the trauma, unexpected outbursts of anger or fear are likely, often incomprehensible to others (unless they are familiar with the circumstances and content of the experienced events). As a rule, a state of heightened autonomic excitability with a tendency toward an elevated level of general alertness is observed. Patients are active, especially in social life; they try to be helpful to others, spend less time on Sleep and rest, are in constant motion, etc. (recall the main character of the French film "Three Colors: Blue", who survived the death of her husband and child but did not lose the will to live—the director shows her several times throughout the film in a swimming pool, where she persistently swims back and forth across the Water alone).

Facultative symptoms of the disorder include depression and suicidal ideation. Secondary alcohol abuse is common, though The rate of development of dependence syndrome is slowed. The onset of the disorder typically follows a certain latency period, and the course is reversible (gradual de-actualization of psychotraumatic experiences occurs). The exceptions are cases where chronic personality change develops following a catastrophe.

In adjustment disorders, the stress factor disrupts the integrity of the patient's social connections or even the broader system of social support and social values. Understandably, this disorder is most frequently observed in refugees or immigrants. Its clinical picture is quite diverse, including depressed mood, anxiety, restlessness, a sense of inability to cope with the current situation, and consequently, a reluctance to remain in it. There is also a reduction in a person's ability to plan their actions, alongside decreased work productivity. In adolescents, this disorder often manifests as delinquent behavior and the commission of antisocial acts that were not characteristic of them prior to the radical change in living conditions.

Beginning in the 1980s, social problems and criminal behavior have spread among young people of Middle Eastern and African descent who moved with their parents to more economically developed European countries. In many cases, this is a manifestation of adjustment disorder, especially since these patterns do not correspond to the subculture in which these children were raised before immigrating with their parents to Europe. Adolescents may particularly exhibit dissocial behavior. In younger children with adjustment disorders, facultative symptoms may include enuresis, prolonged baby talk, or thumb-sucking. For the Diagnosis of this disorder, It is important that its duration should not exceed 6 months (with the exception of prolonged depressive reactions, which may persist in a patient for up to 2 years).

Let us summarize the diagnostic criteria for acute stress reaction, as this is important for Differential diagnosis:

1. An obligatory and clearly visible link between The impact of an unusually severe stressor and the onset of symptoms.

2. Sudden onset of the disorder (or within minutes of the stressor).

3. A mixed and extremely variable clinical picture. Thus, the initial state of stupor may be joined by depression, anxiety, anger, despair, disorganized hyperactivity, or, conversely, social withdrawal.

4. None of the symptoms is so substantial and dominant as to warrant a more specific diagnosis.

5. The patient's verbal output directly or indirectly reflects the content of the psychotraumatic circumstances.

Reactions cease quickly (within a few hours), usually if the removal or Termination of the stressful circumstances is possible.

Treatment of acute stress reaction involves isolating the patient from psychotraumatic circumstances. If this is not possible (e.g., the tragic death of a loved one and the subsequent body identification Procedure), the patient may be prescribed medications that reduce anxiety, fear, and general psychomotor activity (phenazepam, meprobamate, sulpiride, flupenthixol, quetiapine, etc.). To achieve a certain depth and duration of sleep, The Use of hypnotics is desirable (nitrazepam, also known as eunoctin, zolpidem, etc.). It is undesirable to prescribe antidepressants and neuroleptics with a strong sedative action, as the former will worsen the patient's condition due to inevitable vegetative side effects (not to mention that any antidepressants do not act from the first day, but only after a period of accumulation of certain Neurotransmitters in the synapses), while the latter may induce depression followed by suicide.

Dissociative (Conversion) Disorders

The general features common to all dissociative or conversion (formerly called hysterical) disorders are that the individual experiences a partial or complete loss of normal integration between memories of the past, awareness of identity, and behavioral acts. The term "conversion" is used in the sense that an unpleasant emotional state caused by problems and conflicts is transformed into physical symptoms because the person is unable to resolve them.

In dissociative disorders, the following states are distinguished:

1. Dissociative amnesia — memory loss regarding events of a traumatic nature.

2. Dissociative stupor — the same clinical stupor, but triggered exclusively by severe psychological trauma.

3. Trances and possession states — dissociative Disorders of Consciousness in which individuals feel controlled by an external force and unable to resist another's will (not to be confused with psychological automatisms).

4. Dissociative motor disorders — the loss of The ability to perform purposeful actions or even walk independently under The Influence of psychotraumatic circumstances. Milder cases may be limited to dissociative aphonia (a feeling of a lump in the throat).

5. Dissociative seizures — hysterical-type fits that must be distinguished from epileptic seizures, as the treatment for each is fundamentally different.

6. Dissociative anesthesia — the loss of sensitivity caused by psychogenic factors. Its distinctive feature is a mismatch with anatomical innervation zones (such as "stocking" or "glove" distribution).

7. Ganser syndrome — a psychogenic disturbance of consciousness characterized by a classic triad: vorbeireden (approximate Answers), puerilism, and hysterical tremor.

8. Dissociative identity disorder (multiple personality disorder) — under the influence of stress, patients feel fragmented, as if two separate personalities coexist within them and behave differently in various situations.

Thus, among conversion disorders, some do not extend beyond outpatient practice (e.g., dissociative anesthesia), while others are true psychoses requiring hospitalization (such as Ganser syndrome or dissociative stupor). This highlights a key feature of modern classification: the boundaries between psychotic and non-psychotic levels of response are quite frequently blurred.

Somatoform Disorders

Future physicians should be aware of disorders that are essentially psychological in nature—triggered by external or, more commonly, internal conflicts—yet manifest through various somatic "masks." These include somatization disorder, undifferentiated somatoform disorder, hypochondriacal disorder, somatoform autonomic dysfunction, and persistent somatoform pain disorder.

Somatization disorder wears the "mask" of a specific physical illness, yet the physician finds no organic signs to account for the symptoms.

Undifferentiated somatoform disorder resembles the previous condition, but analyzing the patient's reported symptoms makes it very difficult to pinpoint any specific physical illness. Furthermore, this clinical "mask" may change over time.

The clinical picture of hypochondriacal disorder is even less distinct and further removed from conventional physical pathologies.

Somatoform autonomic dysfunction manifests primarily through symptoms of autonomic arousal (palpitations, sweating, Menstrual cycle irregularities, etc.). Clinicians have often misdiagnosed this condition as vegetative-vascular dystonia.

Persistent somatoform pain disorder — the predominant feature here is a complaint of pain that does not respond to standard therapeutic interventions. In obstetric and gynecological practice, a common concept is chronic pelvic pain. Internists are unable to identify its cause, and patients rarely consult psychiatrists because the psychotraumatic factors are often deeply personal.

These disorders can be viewed as "classic" psychosomatic conditions (with Franz Alexander, a Hungarian-born American psychoanalyst, considered the founder of psychosomatic medicine). Regardless of whether we define psychosomatic disorders as bodily conditions originating from psychological factors, or as psychiatric illnesses manifesting through physical symptoms, somatoform disorders are genuine psychosomatic diseases. The American classification of mental disorders groups these conditions together with conversion disorders. While they share significant similarities and underlying mechanisms, there is a fundamental distinction: hysterical symptoms bear a clear and understandable link to the psychotraumatic situation (conflict) that caused them. Using psychoanalytic terminology, such a symptom can be described as a symbol of a repressed desire or an intrapsychic conflict.

Treating somatoform disorders is a complex, time-consuming challenge that requires an individualized psychotherapeutic approach. The greatest difficulties arise when attempting to uncover the core psychotraumatic factor, which the patient either remains unaware of or is reluctant to verbalize.