|General psychopathology||© Tushnik Ghosh|
NEUROSIS AND REACTIVE PSYCHOSIS: Neurosis: traditionally neurosis is not a psychotic disorder, and it is connected with long term severe stress or conflict situations. These disorders contain functional characters, generally accompanied by disturbances of somatovegetative system. The patient shows good insight. He tries to get rid of his disease. Though the prognosis of neurosis is good but the duration of the disease varies from person to person and from symptoms to symptoms. In most of the cases there is complete healing. But sometimes there is no recovery, and the patient get used to his symptoms and shows personality changes of neurotic type. In ICD10, neurosis is subdivided in its basic symptoms: 1. Phobia, F40; 2. Panic attacks, F41; 3. Obsessive disorders, F42; 4. Suppression, F43.2 5. Dissociative psychotic and neurological disorder, F44, 6. Hypochondria and dysmorphophobia, F45.2, 7. Somatovegetative dysfunction, F45.3, 8. Pain, F45.4, 9. Asthenia, F48.0, 10. Depersonalization, F48.1. In Russian school of psychiatry, neurosis is divided into main 3 groups or variants: neurasthenia, neurosis of obsessive condition, and hysteric neurosis. Somatovegetative disorders are present in almost all variants of neurosis. The patient (in the presence of somatovegetative disorder)is demonstrative and demand attention from surroundings in hysteria; he is frightened and anxious in obsessive neurosis; and he feels tired and fatigue in case of neurasthenia. About 2-20% of the world population suffers from neurosis. But all of them do not go to psychiatrists. Most of them do not get treatment. Some go to other medical specialists specially therapists, neuropathologists etc. 20-25% of the patients come to psychiatrists and get treatment. Most of the patients are women with in age 50.
Clinical picture: Neurasthenia (F48.0) - it consists of asthenia. The fundamental signs of this syndrome are agitation and high fatigue. Patient is very sensitive: he cannot tolerate loud sound or bright color, fluctuating temperature. He complains that he feels how his heart beats, or intestine works. He often complains about headache, accompanied by the feelings of tiredness and pulsation and sometimes tinnitus. He complains that he cannot hold his emotions and reacts very bad in minor stress situations. The work ability of the patient is decreased; he complains about memoryloss, intellectual bluntness etc. one of main symptom of this disease is disturbances of sleep: patient feels difficulty in going to bed, sleep is very superficial with many dreams, in the morning most of the patients feel drowsy, no sense of rest. Restlessness, impatience, and agitation of the patient lead to many conflicts with family, parents or with coworkers. These patients often go to therapists, neuropathologists, sexopathologists with complains oh palpitation, vegetative lability, decreased libido, impotency etc. in objective examinations a high B.P. may be found accompanied by extrasystole. This leads to diagnosis vegetative dystonia, deencephalic syndrome or dyskinesia of GIT. Neurasthenia has good prognosis. In katamnesis it is found that on consulting a psychiatrist even 20-30 years after the onset of the disease, about ¾ of the patients are healed.
Obsessive-phobic neurosis – this contains rows of neurotic conditions in which the patient develops obsessive thoughts, actions, fears, remembrance which he takes as disease. This is a strange, uncomfortable feelings of the patient from which he cannot get rid of. The men and the women are equally affected by this disorder. The fundamental role which is taken as one of the main cause of the disease is the constitutional-personality trait predisposition. These patients are thoughtful, look for logic, and their psychological defense mechanisms are self analysis and try to control the expression of their emotions. This is also known as psyc-asthenia. It is classified as F48.8 in ICD10. The most common symptom of obsessive phobic neurosis is phobia. Often the patient has phobia of getting somatic or infectious diseases – F45.2, cardiophobia, syphilophobia, AIDS phobia etc. Other types of phobia are claustrophobia – fear in closed place (in bus, train, lift etc); agarophobia F40.- fear in public place, etc. the patient suffering from phobia tries to avoid situations which leads to phobia Obsession is another variant of this disorder which is frequently met. The patient cannot forget some events. He thinks about the same event many times until he feels tired. This patient complains of lack of concentrations, fatigue and agitation. If obsession is nit treated for a long time and if it lasts without spontaneous remission, it may turn into obsessive action or compulsion, F42.1. We discussed about it earlier. There is another variant called panic attack, F41.0. It is repeat ting attacks of intensive fear which never last more than few minutes. It is thought that most of the panic attacks are closely related to chronic stress.
Hysteric neurosis (dissociative disorder): this is a psychogenic functional disease especially presented as extreme various somatic, neurologic and psychiatric disorders as self defense mechanism. In women it is observed 2-5 times more. The symptoms start either at an early age (teenage) or near menopause. This disorder is generally seen in people of medium education level, extrovert people, and lonely people. The mail predisposition of the disorder is psychological infantilism. Pathological presentation is various. There may be fit, somatic, vegetative and neurological disorders. The occurrence of hysteric attack may remind endogenous disorders. To differentiate from above mentioned disorder we must notice its psychogenous origin and demonstrative characters. In comparison to organic disorder, the clinical picture of hysteria is created by its patient. The way patient wants to show it, hysteria comes the same way. The patient suffering from hysteria wants to get attention from the surroundings. An extra psychotrauma increases the intensity of the symptoms. The symptoms of hysteria cannot be written as I told earlier; it’s the way the patient wants to show it. Besides the symptoms change from situation to situation. The most common symptoms are hysteric paralysis, hysteric fit, pain, disturbances of coordination, loss of voice, dyspnea etc. We will discuss about hysteria (dissociative disorder) in more details in chapter epilepsy.
Neurotic disorders are many in numbers. We have discussed the fundamental disorders among them. Following will be a brief discussion of other few neurotic disorders. Movement disorder (F44.4) - it includes paralysis, paresis, weak feeling in extremities, ataxia, tremor, hyperkinesias, blepharospasm, apraxia, aphonia, dysarthria etc. in the past there were convulsions too. Sensory disturbances (F44.6) –presented as different kinds of disturbances of senses or feeling as anesthesia, hyperesthesia, paresthesia (itch, burning sensation), pain (F45.4), loss of hearing and vision. The disturbances of senses are not on the places of nerve innervations. Hysteric pains are very demonstrative, unusual, and occur at different parts of body. The patient compares headache with pressure by hammer, sudden acute pain in spine, or breaking pain in joints. These complains often mislead other specialists and are one of the main causes of wrong surgical diagnosis. Somatovegetative disturbances (F45) – it can be seen in any organ system. GIT disorder – disturbances of swallowing, feeling of foreign body in thought, nausea, vomiting, absence of appetite, meteorism, constipation and diarrhea. Disturbances in the chest region (heart and lung) can be presented as dyspnea, feeling of inadequate air, pain, palpitation, arrhythmia. Urogenital sphere complaints can be frequent urination, feeling of full bladder, vaginism, false pregnancy etc. Psychic disorder – it occurs as psychogenous amnesia (F44.0), hysteric illusion and hallucination, emotional lability, and are accompanied by crick, loud cry etc.
Treatment of neurosis: the fundamental basic treatment is psychotherapy with psycho pharmacotherapy. Broadly used are physiotherapy, reflex therapy, massage, diet therapy etc. in most of the cases treatment is out patient. But sometimes hospitalization is needed. For neurasthenia, rest is recommended. The patient is prescribed nootropic and anxiolytics for anxiety, restlessness, sleeplessness, and increased muscle tone. Mild neuroleptics like thioridazine, cholprothixene, serdulide are used. For low mood, mild antidepressants are considered. Symptomatic treatment for somatovegetative disturbances symptoms is maintained. In case of obsessive neurosis, psycho pharmacotherapy is the main treatment. Antidepressants are the drug of choice for the last few decades. Clomipramine, imipramine, MAO inhibitors, SSRI are used. To control the acute attack of fear benzodiazepines are used. Alprazolam is the drug of choice. Diazepam is also used. For long term effect phenazepam, alprazolam cholprothixene are used. It is proved that anticonvulsants are good for prophylaxis of attacks of fear. Carbamazepine is used in this case. In chronification of the process neuroleptics like alimemazine, thioridazine, chorprothixene, perphenazine are used. Along with medication psychotherapy is highly recommended. For hysteric neurosis, the basic treatment is psychotherapy. Basic methods are self-interferance and hypnosis. Medication is prescribed in high excitement –neuroleptics and in depression –antidepressants.
Clinical variants of reactive psychosis- most of the reactive psychosis are temporary (last for short time). This disorder is seen very less in clinical practice. Frequency of this disorder increases during social hazards (war, earthquake etc). Out of all the clinical variants of reactive psychosis we will discuss here affective-shock reaction, Ganzer syndrome and reactive paranoid.
Affective-shock reaction: This is acute reaction at stress (F43.0). it develops as a result of sudden extreme strong psychotrauma (catastrophe, accidents, murder, fire, violence etc.). This type of psychotrauma is so strong that it can lead to psychic disorder to any person. Immediately after the trauma is noticed either reactive stupor (impossible to move, can’t answer questions, cannot run away from the site of event etc) or reactive excitement (chaotic activity, crick, panic, run etc). In both of the cases psychosis is accompanied by obscured consciousness and partial or complete amnesia is observed. Both of the symptoms may cause death of the person. During fire, a person in reactive psychosis may jump from the window. This is the disorder which make people panic during catastrophe 9from a few minutes to few hours). Special treatment as rule is not required. After the event, most of the people become normal. Some people retain remembrance of the events which come as a thought. This disturbs the people. These people are those who literally suffered during the catastrophe. This disorder is called posttraumatic stress disorder F43.1. In situations significant violence at a person’s social status (court cases, mobilization, serving army, sudden divorce etc) may bring hysteric psychosis. The mechanism of occurrence of this is as same as other hysteric phenomena, but the severity of the disorder goes till psychosis and insight is very poor. Organic defect in brain, or demonstrative trait of character strengthen the diagnosis. Clinical picture is very various. Puerilism: it is presented as infantile behavior. The patient shows that he is still young, call the surrounding people as uncle, aunt etc. he plays with toys, sucks finger etc. Pseudodementia: this is not a true dementia. The patient shows that he forgets everything, as if complete loss of memory and intellect. He answers 2+2=5. But this answer shows that the patient knows something. His answer is not correct but near to correct. The patient demonstrates that he cannot dress up, eat independently, doesn’t know how many fingers he has in his hand etc. but we must remember that according to law of Rebot, these things a person hardly forgets. Hysteric twilight states (hysteric fuga F44.1, hysteric trance F44.2, hysteric stupor F44.3,):this occurs suddenly with relation to psychotrauma and is expressed by disturbances in orientation, odd actins and activity, sometimes hallucination etc. After the event, there is amnesia.
Ganzer’s syndrome (F44.80): all the above mentioned disorders may be seen sometimes simultaneously. The patient cannot answer to simple questions, cannot name the parts of his body, and cannot say which side is his right side. There are infantilism and disorientation of time, place and personality. Though the patient answers wrong but his answer shows that he understood the question. Hallucination may also be observed. This is called Ganzer’s syndrome. The patient shows characteristics of beast: walks with four feet, lick the plate with tongue during eating like a dog, barks, shows teeth, and tries to bite.
Reactive paranoid (F23.31): This is delusional psychosis occurs as a reaction at psychological stress. The delusion is not systematic and highly emotional (accompanied by anxiety and fear etc). Sometimes auditory deception is noticed. The occurrence of the disorder is typically during sudden change of place (war front, long trip to unknown places etc), social isolation, and huge responsibility of a person when any mild mistake may cause adversary to family. In most of the cases, the delusion in reactive paranoid doesn’t last long. It responds well to treatment. Sometimes medication is not needed if the duration of psychotrauma is very less or it is withdrawn.
Before we go to next section we must briefly discuss reactive depression (F32 or F43.2). Symptoms of reactive depression are as same as the symptoms of depression. Continuous feelings of sadness, helplessness, thought and motor blocking and often suicidal attempts are main symptoms. In comparison to endogenous depression, all the sufferings of the patient are closely related to psychotrauma that the patient experienced (death of family member, separation, loss of job, retire from job, change of place, financial crisis etc.). Any remembrance of the psychotrauma or loneliness exacerbates the symptoms. Ideas of guilt, self-deprive, may follow. Repeated attacks are rare. In ICD10 it is considered as unipolar depression or single depressive attack, F32. In case of mild low mood, closely related to stress are explained as depressive neurosis, F43.2.
Treatment: when a patient comes to doctor with reactive psychosis, he shows psychomotor excitement, panic, fear, and anxiety. The first thing to be done here is to control and monitor the condition of patient and make him relax. IV anxiolytics or tranquilizers (diazepam, lorazepam, alprazolam) are introduced. If tranquilizers are not effective, levomepromazine, chlorprothixene are given till 100 mg. Affective-shock reaction doesn’t need any special treatment. In case the psychosis prolongs, mild tranquilizers are administered. Hysteric psychosis is well treated by psychotherapy. A good effect may also be observed by administration of levomepromazine, chlorprothixene, thioridazine, periciazine etc. Reactive depression is treated by sedative antidepressants and tranquilizers (amitriptyline, mianserine, alprazolam, diazepam etc). For older and somatic patients, fluvoxamine, fluoxatine, lorazepam, etc are used. When the patient is ready to talk or show interest in consultation with doctors, psychotherapy is started. For reactive paranoid antipsychotic or neuroleptics are widely used. Haloperidol is drug of choice.
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