Clinical Assessment and Diagnosis of Psychiatric Disorders
Module 3
Unit 7 : Neurotic, stress related and somatoform disorders – Phobia, Obsessive Compulsive
Disorder, Panic Disorder
INTRODUCTION
Neurotic stress related and somatoform disorders have a common historical origin with the concept of
neurosis and association of a substantial proportion of these disorders with psychological causation.
About one third of population in developed countries will suffer from neurotic neurotic disorders during
its lifetime course.
Mixed of symptoms, especially anxiety and depressive ones are common in these disorders
with the exception of social phobia their frequency is higher in women than in men.
PHOBIC DISORDER
Phobia is defined as an irrational fear of a specific object, situation or activity often leading to persistant
avoidance of feared object, situation or activity. The common types of phobias are;
Agoraphobia
Social phobia
Specific phobia
Some common features of phobia are;
Presence of feared object, situation or activity.
The fear is out of proportion to the dangerousness perceived.
Patient recognizes the fear as irrational and unjustified.
This leads to persistent avoidance of that particular object, situation or activity.
Gradually this results in marked distress and restriction in the freedom of mobility.
AGORAPHOBIA
Agoraphobia is an example of irrational fear of situations. It is the commonest type of phobia in clinical
practice. It is characterised by an irrational fear of being in places far away from familiar setting of
home. Although it was earlier thought to be a fear of open spaces only ,now it includes fear of open
spaces, public spaces, crowded spaces, and any other place from where there is no easy way to escape.
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,The patient is afraid of all the places or situations from where escape may be perceived to be difficult, if
he suddenly develops embrassing or incapacitating symptoms(classical symptoms of panic).A full-blown
panic attack may occur (agoraphobia with panic disorder), or a few symptoms only(eg; dizziness or
tachycardia)-(agoraphobia with panic disorder).
As agoraphobia increases, there is a gradual restriction in normal day-to-day activities. The activities
may restrict that the person becomes self imprisoned in his home.
SOCIAL PHOBIA
This is an example of irrational fear of activities or social interactions, characterised by an irrational fear
of performing activities in the presence of other people or interacting with others. There is a marked
distress and disturbance in routine daily functioning.
Some examples are, fear of blushing(erythrophobia), eating in company
of others, public performance, participating in groups, writing in public, speaking to strangers, dating,
speaking to authority figures and urinating in public lavatory. Sometimes alcohol and other drugs are
used to overcome the anxiety occurring in social situations.
SPECIFIC PHOBIA
Specific phobia is an example of irrational fear of objects or situations. It is characterised by an irrational
fear of a specific object or situation. Anticipatory anxiety leads to persistent avoidant behavior.
The disorder is diagnosed only if there is marked distress or/and avoidance in daily functioning, in
addition to the specified object or situation. Some examples includes acrophobia(fear of
height),xenophobia(fear of strangers),claustrophobia(fear of closed places)algophobia(fear of
pain),zoophobia(fear of animals).
PREVALENCE
Studies indicate that the lifetime prevalence of phobia around the world ranges from 3-5%,with fears
and phobias.
ETIOLOGY
Psychodynamic theory
In phobia secondary defense mechanism is displacement . By using displacement , anxiety is transferred
from a really dangerous or frightening object to a neutral object. The neutral object chosen
unconsciously is the one which can be easily avoided in day-to-day life, in contrast to the frightening
object.
In agoraphobia, loss of parents in childhood and separation anxiety have been theorised to contribute to
causation. From a psychobiological percepective,the traumatic experiences of childhood may affect the
child's developing brain in such a manner the child becomes suceptable to anxiety and fear.
The behavioural theory explain phobia as a conditioned reflex. Initially the anxiety provoked by a
naturally frightening or dangerous object occurs in contiguity with a second neutral object. If this
happens enough, the neutral object becomes a conditioned stimulus for causing anxiety.
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,Biological theories
All phobias, especially agoraphobia are closely linked to panic disorders. It has-been suggested that
probably the biological models of panic disorders apply to phobias too.
COURSE
Phobias are generally common in women with an onset in late second decade. The course is usually
chronic with gradually increase restrictions in daily activities. Sometimes phobias are spontaneously
remitting.
TREATMENT
Most patients with phobic disorder rely on avoidance to manage their fears and anxieties.
The treatment model is usually multi-model. The patient with more than one phobia and presence of
panic symptoms often seek treatment earlier.
PSYCHOTHERAPY
Psychodynamically oriented psychotherapy is not usually helpful in treatment of phobias. This
approach is however indicated when there are characterological or personality difficulties as
well. Supportive psychotherapy is helpful adjust to behaviours therapy and drug treatment. CBT
can be used to break the anxiety patterns in phobic disorder. It is usual in combine CBT with
behavioural techniques.
BEHAVIOURAL THERAPY
Important techniques like flooding,systamatic desensistation,explosure and response
prevention, Relaxation techniques are useful
DRUG TREATMENT
Benzodiazepines are useful in reducing the anticipatory anxiety. Alprazolam is stated to have
antiphonic ,anti-panic and anti-anxiety properties. The other drugs used include clonazepam and
diazepam. However long-term use of benzodiazepines is fraught with the dangers of tolerance
and dependence.
Other antidepressants such as imipramine(TCA) and phenelzine (MA01) are useful in treating panic
attacks associated with phobias, there by decreasing distress.
OBSESSIVE-COMPULSIVE DISORDER
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 or image but is perceived as ego-alien.
It is recognised as irrational and absurd (insight is present).
Patient tries to resist against but it is unable.
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, Failure to resist, leads to marked distress.
An obsession is usually associated with compulsion. A compulsion is defined as:
A form of behavior which is usually follows obsessions.
It is aimed at either preventing or neutralising 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 realises the irrationality of compulsion.
The behaviour is performed with a sense of subjective compulsion.
Compulsions may diminish the anxiety associated with obsessions.
PREVALENCE
The worldwide prevalence of OCD is approximately 2% og the general population. Females are affected
at a slightly higher rates than male adulthood, although male are commonly affected in childhood.
EPIDEMOLOGY,COURSE AND OUTCOME
In India, OCD is more common in unmarried males, while in other countries, no gender differences are
reported. This disorder is commoner in persons from upper social strata and with high intelligence.
Recent studies shows the lifetime prevalence of OCD to be as high as 2-3%
through the Indian date shows a lower prevalence rate. Although OCD have a steady chronic cause, the
longitudinal profile of this disorder can also be episodic.
A summary of long term follow-up studies shows about 25% remained unimproved over time ,
50% had moderate to marked improvement while 25% has recovered completely.
ETIOLOGY
Several caustic factors have been explored in the past but no clear etiology of obsessive compulsive
disorder is known yet. Some important theories include ;
Psychodynamic theory
Sigmund Freud found obsessions and phobias to be psychogenitically related.
Undoing: This defense mechanism leads to compulsions which prevent consequences of obsessions.
Reaction formation results in the formation of obsessive compulsive personality traits rather than
contributing symptom, while displacement leads to formation of phobic symptoms.
Behavioural theory
This theory explains obsessions as conditioned stimuli to anxiety. Compulsions have been described with
obsessions.
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