These disorders constitute the largest portion of psychiatric disorders, accounting for 50% of admissions to psychiatric hospitals, 75% of patients seen in psychiatric outpatient clinics, and over 90% of the psychiatric disorders seen and managed by general practitioners. There is an overlap between neuroses and personality disorders, although in general they can be distinguished.
The neuroses are defined below. Personality disorders are deeply ingrained maladaptive patterns of behaviour generally recognizable by the time of adolescence and often becoming less obvious in middle or old age. The personality is abnormal either in the balance of itscomponents, its quality or expression, or in its total aspect, and this deviation has an adverse effect upon the individual or on society.
The psychopath is a person who, as described by the Mental Health Amendment Act (1982), manifests a persistent disorder or disability of mind (whether or not this includes significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct. The individual tends to be emotionally cold and callous, shows little remorse or ability to learn from previous mistakes, tolerates frustration poorly, is impulsive and has considerable difficulty sustaining roles requiring persistence and consistency, such as jobs, personal relationships and financial obligations.
Anxiety neurosis
An anxiety neurosis is a condition in which anxiety dominates the clinical symptoms.
CLINICAL FEATURES
The patient looks worried, has a tense posture, restless behaviour, a pale skin, and sweaty hands, feet and axillae.
The physical and psychological symptoms (Table 19.21) result from either overactivity of the sympathetic nervous system or increased tension in the skeletal muscles. Sleep is disturbed: the patient has difficulty in getting to sleep because of worry and restlessness, and when asleep wakes intermittently and may have unpleasant dreams. Another feature is the hyperventilation syndrome (Information box 19.4).
Sometimes anxious patients have the conviction that they suffer from heart disease. The conviction is accompanied by palpitations, fatigue, breathlessness and inframammary pain. The terms cardiac neurosis, effort syndrome and neurocirculatory asthenia used to be applied to the disorder. l3-blockers are sometimes useful in controlling these symptoms.
Types of anxiety
Anxiety may be divided into the following categories:
A MORE OR LESS CONTINUOUS STATE OF ANXIETY that fluctuates to some extent in response to environmental circumstances
PANIC ATTACKs-sudden and unpredictable attacks of
Physical
Gastrointestinal
Dry mouth
Difficulty in swallowing
Epigastric discomfort
Flatulence
Diarrhoea (usually frequency)
Respiratory
Feeling of chest constriction
Difficulty in inhaling
Overbreathing
Cardiovascular
Palpitations
Awareness of missed beats
Feeling of pain over heart
Genitourinary
Increased frequency
Failure of erection
Lack of libido
Nervous system
Tinnitus
Blurred vision
Dizziness
Headache
Sleep disturbances
Psychological
Apprehension and fear
Irritability
Difficulty in concentrating
Distractability
Restlessness
Sensitivity to noise
Depression
Depersonalization
Obsessional symptoms
Physical and psychological symptoms of anxiety.
Features
Panic attacks-fear, terror and impending doom-accompanied by some or all of the following:
Dyspnoea
Palpitations
Chest pain or discomfort
Choking sensation
Dizziness
Paraesthesiae
Sweating
Carpopedal spasms
Cause
Overbreathing leading to a decrease in Paco, and an increase in arterial pH
Diagnosis
A provocation test-voluntary overbreathing for 2-3 min-provokes similar symptoms; rebreathing from a paper bag relieves them
Management
Explanation and reassurance is given
The patient is trained in relaxation techniques and slow breathing
The patient is asked to breathe into a closed paper bag.
Information box 19.4 The hyperventilation syndrome.
anxiety that are usually accompanied by severe physical symptoms
PHOBIC ANXIETY, which is anxiety triggered by a single stimulus or set of stimuli that are predictable and that normally cause no particular concern to others, e.g. agarophobia, claustrophobia
AN ANXIOUS PERSONALITY-an individual who has a lifelong tendency to experience tension and anxiety, and to have a worrisome attitude towards life and a constant anticipation of setback and stress.
AETIOLOGY
Genetic factors
Anxiety neurosis occurs in 15% of relatives of affected patients compared with 3% of the general population. (The genetic role is less important in phobic anxiety.)
Psychodynamic theory
This is a theoretical explanation that suggests that anxiety neurosis reflects overwhelming stress, anxiety and difficulties in the child-parent relationship in early childhood or even at birth. Psychoanalysts also interpret phobic neurosis as an unconscious avoidance of unacknowledged feelings of temptation (usually sexual), the phobia representing a displacement of the real fear (e.g. the agoraphobic patient is really afraid of the feelings of temptation aroused when meeting people in the street).
Learning theory
Anxiety is regarded as a fear response that has been attached to another stimulus through conditioning.
TREATMENT
Psychological treatment
For many brief episodes of anxiety neurosis, a discussion with a doctor involving explanation and reassurance concerning the nature of physical symptoms of anxiety is usually sufficient. Relaxation training can be as effective as drugs in relieving mild or moderate anxiety. Such an approach uses an elaborate system of exercises designed to bring about relaxation of individual groups of skeletal muscles and to regulate breathing. A further development is anxiety management training, which involves two stages. In the first stage, verbal cues and mental imageryare used to arouse anxiety. In the second stage, the patient is trained to reduce this anxiety by relaxation, distractionand reassuring self-statements. Both of these approaches are forms of behaviour therapy.
The term behaviour therapy is applied to psychological treatments derived from experimental psychology and intended to change symptoms and behaviour. A variety of such treatments, including desensitisation, flooding and programmed practice, are now used in the management of anxiety, phobias and obsessions. Non-behavioural treatments include individuals and group-based psychotherapies.
Physical treatment
Drugs used in the treatment of anxiety can be divided into two groups: those that act primarily on the CNS and those that block peripheral autonomic receptors. The main group of centrally acting anxiolytic drugs are the benzodiazepines. They appear to bind to specific receptorson neuronal cell membranes, producing a facilitation of the effects of the inhibitory transmitter y-aminobutyric acid (GABA). Diazepam (5 mg twice daily to 10 mg three times daily in severe cases) and nitrazepam have relatively long half-lives (20-40 hours) and are more suitable as antianxiety drugs than as hypnotic drugs, whereas oxazepam, temazepam and lorazepam have shorter halflives and may be used as hypnotics. Overdosage, which may be accidental or deliberate, produces drowsiness, sleep, confusion, incoordination, ataxia, diplopia and dysarthria. Physical as well as psychological dependence has been described, and convulsions have occurred on withdrawal of such drugs after longterm administration. The withdrawal syndrome (Table 19.23) is particularly severe when high doses have been given, e.g. 30 mg of diazepam daily or more. Tolerance can occur with repeated doses and can lead to an escalation
of dosage. Thus, if a benzodiazepine drug is prescribed for anxiety, it should be given in as low a dose and for as short a time as possible (i.e. for not more tha n3-4 weeks). A withdrawal programme includes changing therapy to diazepam followed by a very gradual reduction in dosage.
Many of the symptoms of anxiety are due to an increased release of adrenaline and noradrenaline from
the adrenal medulla and the sympathetic nerves. Thus, adrenergic blocking drugs such as propranolol (20-40 mg two or three times daily) are effective in reducing symptoms such as palpitations, tremor and tachycardia.
